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Educational audiology handbook [Third ed.]
 9781635501087, 1635501083

Table of contents :
List of Appendices
Preface
Contributors
Section I: Educational Audiology Practices
Chapter 1. Legislative and Policy Essentials
Legislation and Policies
Key Legislation
Key Initiatives and Events in Deaf Education
Inclusion
The Deaf Child Bill of Rights
Early Hearing Detection and Intervention
The National Association of State Directors of Special Education
The Council for Exceptional Children, Division for Communication, Language, and Deaf/Hard of Hearing
Legislative Initiatives
Summary
Suggested Readings and Resources
Appendices
Chapter 2. Roles and Responsibilities of Educational Audiologists
Roles of Educational Audiologists
Educational Audiologists as Service Coordinators
Educational Audiologists as Instructional Team Members
Educational Audiologists as Consultants
Educational Audiologists in Schools for the Deaf
Responsibilities of Educational Audiologists
Identification
Assessment
Habilitation
Hearing Loss Prevention
Counseling and Coaching
Amplification, Cochlear Implants, and Other Assistive Technology
Ethical Considerations
Educational Audiology Service Delivery Models
School-Based Audiology Services
Contracted Audiology Services
Combined School-Based and Contractual Agreement
Telepractice
Establishing and Expanding Educational Audiology Services in the Schools
Reimbursement for Educational Audiology Services
Dispensing Personal Hearing Instruments
Cerumen Management
Support for Early Hearing Detection and Intervention
Training for Educational Audiologists
Summary
Suggested Readings and Resources
Appendices
Chapter 3. Partnering With Families With Janet DesGeorges
Positive Attitudes
Rapport
Respect
Trust
Effective Communication
Informational Guidance
Quantity of Information
Types of Information
Parent-to-Parent Communication
Parent Involvement
Committee/Task Force Work
Classroom Support
Parent Activities
Difficult Situations
Parent/School Disagreement Over Individualized Education Program Services
Request for a Specific Brand of Amplification
Influence of Private Provider on School Services
Families That Have Difficulty Being Involved
Differing Opinions on Communication Modality
Summary
Suggested Readings and Resources
Appendices
Chapter 4. Hearing Screening and Identification
State Hearing Screening Mandates
Screening Requirements in Private Schools, Charter Schools, and Other Nontraditional Education Settings
Purposes of Hearing Screening and Identification Programs
Professional Guidelines
Age Considerations
Prevalence Considerations
Resources for Hearing Screening and Identification Programs
Personnel and Time
Scheduling Considerations
Screening and Identification Program Considerations
Early Childhood
School-Age Children and Youth
Screening and Identification Procedures
Visual Inspection
Auditory Brainstem Response
Otoacoustic Emissions
Pure-Tone Audiometry
Tympanometry
Behavioral Observation
Screening and Identification Protocols
Infants and Young Children
School-Age Children and Youth
Hearing Screening and Monitoring Children Who Cannot Respond to Traditional Measures
Screening Personnel
Audiologists
Speech-Language Pathologists
Parent Volunteers, School Nurses, and Paraprofessionals
Training of Support Personnel
Screening Equipment and Maintenance
Screening Equipment
Equipment Maintenance/Calibration
Infection Control
Screening Environment
Location of the Screening Room
Noise Levels
Other Factors
Organization of Screening and Identification Programs
Scheduling of the Screening
Activities Prior to the Screening
Activities During the Screening
Follow-Up Procedures
Follow-Up Screening for Middle Ear Conditions and Medical Referrals
Referrals for Audiological Evaluations
Educational Screening
Data Management and Reporting
Determining the Effectiveness of Hearing Screening and Identification Programs
Data from Screening Program
Sensitivity and Specificity
Cost Effectiveness
Summary
Suggested Readings and Resources
Appendices
Chapter 5. Assessment
The Cross-Check Principle in Educational Audiology
Basic Assessment of Hearing
Case History
Otoscopy and Visual Inspection
Behavioral Assessment
Physiological Assessment
Modifications for Special Populations
Pure-Tone Modifications
Speech Modifications
Monitoring Hearing Sensitivity
Types of Monitoring
Schedules for Monitoring
Additional Audiometric Information and Functional Hearing Assessment
Speech Recognition for Sentences and Phrases
Speech Perception in Noise Testing
Listening in Noise
Speech Recognition With Visual Support
The Functional Listening Evaluation
Auditory and Listening Development Skills
Audiometric Assessment Considerations Without a Sound Booth
Cultural Considerations
Assessment of the Educational Effects of Hearing Status
The Classroom Listening Assessment
Use of Teacher Checklists
Interpretation of Audiological Information
Need for Comprehensive Evaluation
Communication of Assessment Results
Audiograms
Written Reports
Teacher Letters
Letters to Physicians or Other Professionals
Telephone or Personal Conferences
E-mail, Texting, and Web-Based Communication
Documentation
Privacy Issues
Personal Vulnerability and Safety
Summary
Suggested Readings and Resources
Appendices
Chapter 6. Auditory Processing Deficits With Lisa R. Cannon
Auditory Processing Deficit Basics
Terminology and Definitions of Auditory Processing and Auditory Processing Deficits and Disorders
Criteria for Determination of an Auditory Processing Disorder
Practice Guidelines: The Role of the Audiologist and Other Professionals
APD and Other Disorders
An Educational Model of Auditory Processing
APD and Multitiered Systems of Support
Implementing a School-Based APD Program
Step 1. Developing the APD Team and Philosophy
Step 2. Referral and Screening
Step 3. Assessment for APD
Step 4. Eligibility for Services
Step 5. Intervention
Summary
Suggested Readings and Resources
Appendices
Chapter 7. Classroom Acoustics and Other Learning Environment Considerations
Learning Environments and At-Risk Students
Listening and Learning Challenges
Lighting and Learning Challenges
At-Risk Students
Universal Design for Learning
Properties of Classroom Acoustics
Noise
Signal-to-Noise Ratio
Reverberation
Inverse Square Law and Critical Distance
Classroom Acoustics and Speech Perception
Effects of Noise on Speech Perception
Effects of Reverberation on Speech Perception
Combined Effects of Noise and Reverberation on Speech Perception
Effects of Classroom Acoustics on Teachers
Classroom Acoustics Standard
History and Development of the Standard
Current Standard Status
Classroom Audio Distribution Systems
Conformance and Tolerance Verification
Standard Adoption
Classroom Acoustics Resolutions and Guidelines
Measuring Classroom Acoustics
Classroom Observation
Instrumentation and Software Programs
Classroom Noise Measurements
Classroom Reverberation Measurements
Estimating Critical Distance
Role of the Educational Audiologist
Management of the Learning Environment
Summary
Suggested Readings and Resources
Appendices
Chapter 8. Hearing Instruments and Remote Microphone Technology With Erin C. Schafer
Rationale for Hearing Instruments and Remote Microphone Technology
Recent Trends and Regulatory Considerations
Regulations
The Role of Case Law
Professional Practice Standards and Scope of Practice Considerations
The Responsibility of Public Education
Keeping Up with Technological Advancements
Equipment and Space Requirements
Assessment of Hearing Instrument and Remote Microphone Technology in Children and Youth
Candidacy and Candidacy Considerations
Device Selection Considerations for Remote Microphone Technology
Personal Hearing Instruments and Remote Microphone Technology Options
Hearing Aids
Cochlear Implants
Remote Microphone Technology
Implementation and Management of Hearing Technology
Fitting and Verification
Orientation and Training
The Usage Plan
Validation
Monitoring and Equipment Management
Strategies to Implement the American Academy of Audiology Hearing Assistance Technology Guidelines
Other Assistive Technologies
Summary
Suggested Readings and Resources
Appendices
Chapter 9. Case Management and Habilitation
Planning Case Management and Habilitation
The Importance of Service Coordination
Facilitating Effective Case Management
Implementing Audiological Habilitation
Direct Services
Indirect Services
Services for Special Populations
Students With Unilateral Hearing Conditions, Single-Sided Deafness, or Minimal Hearing Loss
Students With Auditory Processing Deficits and Auditory Neuropathy Spectrum Disorder
Students With Multiple Learning Challenges
Students Using Cochlear Implants
Early Hearing Detection and Intervention
Inclusion
Summary
Suggested Readings and Resources
Appendices
Chapter 10. Supporting Wellness and Social-Emotional Competence With Carrie Spangler
A Wellness Perspective
Social-Emotional Development
Bullying and Victimization
Skills and Strategies for Students to Address Wellness and Social Competence
Self-Determination Skills
Self-Advocacy Skills
Counseling Strategies
Reflective Listening
Self-Assessment
Extending Conversations and Coaching
Networking for Students
Peer Mentors and Role Models
Referring for Additional Services
Summary
Suggested Reading
Appendices
Chapter 11. Developing Individual Plans
The Special Education Process
Step 1: Identification: Concern About the Child
Step 2: Referral to Special Education and Assessment
Step 3: Determination of Eligibility
Step 4: The Individualized Education Program Meeting
Step 5: Review and Revision of the Individualized Education Program
Due Process Procedures
The Educational Audiologist’s Role in the Special Education Process
The Individualized Education Program
Consideration of Special Factors: Communication Considerations
Services, Placement, and Least Restrictive Environment Considerations
Services for Parents
Transition Planning
Individualized Education Program Goal Development
Section 504 Plan
The Services Plan
The Individual Family Service Plan
Eligibility Criteria
Purpose of the Individual Family Service Plan
Individual Family Service Plan Requirements
The Role of Case Law
Summary
Suggested Readings and Resources
Appendices
Chapter 12. Prevention of Noise-Induced Hearing Loss and Tinnitus in Youth With Deanna K. Meinke
Epidemiology Estimates of Noise-Induced Hearing Loss in Youth
Epidemiology of Noise-Induced Tinnitus in Youth
Rationale for Hearing Loss Prevention Targeting Youth
Public Health Role for Audiologists
Raising Public Awareness in the School Setting
Noise Awareness and Prevention Programs
Education to Prevent Noise-Induced Hearing Loss
Dangerous Decibels
Hearing Screenings for At-Risk Individuals
Advocating for Public Policies
Challenges and Future Directions
Section II: Collaborative Practices and Program Effectiveness
Chapter 13. Supporting the Educational Team With Carrie Spangler
Formal Inservice
Preparation
Presentation
Follow-Up
Continuing Contact With Participants
Coaching and Mentoring
Educational Coaching
Coaching for Educational Audiologists
Mentoring
Summary
Suggested Readings and Resources
Appendices
Chapter 14. Educational Considerations for Students Who Are Deaf or Hard of Hearing
Critical Issues in Deaf Education
Accountability and Oversight
Communication and Communication Access
Quality Instruction
Evidenced-Based Practices
Students Not Eligible for Special Education
Maintaining Teacher of the Deaf and Related Service Provider Positions
Parent and Family Engagement
Early Hearing Detection and Intervention and Early Childhood Education
Technology
Deaf Versus Hard of Hearing
National Association of State Directors of Special Education: Ten Essential Principles for Effective Education of Deaf and Hard of Hearing Students
What Is Research Saying?
Legislative Initiatives in Deaf Education
Language Acquisition and Literacy Accountability
Deaf Child’s Bill of Rights
Hearing Aid Insurance
Educational Assessment
Transition Planning
Best Practice Considerations for Educating Children and Youth Who Are Deaf or Hard of Hearing
Know Your Students
Adopt Program Standards
Conduct a Program Review
Identify Evidence-Based and Consensus-Based Practices
Utilize Progress Monitoring
Incorporate Expanded Core Curricula
Utilize Deaf and Hard of Hearing Peers and Role Models
Engage Parents and Caregivers
Summary
Suggested Reading
Appendices
Chapter 15. Collaborative School–Community Partnerships
Establishing and Maintaining Relations With Community Resources
Identifying and Interfacing With Community Resources
Identifying Resources Through a Community Survey
Potential Community Partners
Updating the Community Resource Survey
Marketing and Advocacy for Educational Audiology Programs
Increased Name Recognition
Broadened Visibility of Services
Increased Knowledge of Program Outcomes
Internal Marketing
External Marketing
Developing and Fostering Creative Collaborative Efforts
Information and Materials to Share
Facilitating Interprofessional Collaboration
Fostering Creative Community Collaboration
Legal and Ethical Issues
Summary
Suggested Readings and Resources
Appendices
Chapter 16. Program Development, Evaluation, and Management
Program Development
Laying the Foundation
Needs Assessment
Planning
Program Evaluation
Assessment of Existing Audiology Services
Planning for Improvement
Implementation of New Services
Measuring Effectiveness
State Model Evaluation Systems
Program Management
Annual and Monthly Scheduling
Day-to-Day Scheduling
Office Support
Data Management
Forms
Budget and Finances
Facilitating Meetings
Challenges
Summary
Suggested Reading and Resources
Appendices
Chapter 17. Reflections and Future Directions With Sarah Florence
Emerging Themes
The Educational Audiologist as an Integral Member of the Multidisciplinary Team
The Emphasis on Accountability, Specific Student and Program Outcomes, and Use of Cost-Effective Strategies to Address Critical Issues
Societal Factors
Promoting Hearing Loss Prevention as a Social Health Problem
Remote Audiology Services
Remote Educational Audiology Services Model
Remote/Onsite Hybrid Model
Remote Support of Onsite Educational Audiologists
Service Considerations
Remote Technology Tools
Summary
References
Index

Citation preview

Johnson Seaton

Educational Audiology Handbook, Third Edition, offers a roadmap for audiologists who work in schools or other providers who support school-based audiology services. As the gold standard text in the field, the handbook provides guidelines and blueprints for creating and maintaining high-quality educational audiology programs. Educational audiologists will also find guidance for achieving full integration into a school staff. Within this comprehensive and practical resource, there are a range of tools, including assessment guidelines, protocols and forms, useful information for students, families, school staff, and community partners, as well as legal and reference documents. New to this Edition: • All chapters revised to reflect current terminology and best practices • A new feature called “Nuggets from the Field” which offers practical information from experienced educational audiologists currently working in school settings • Revised and updated chapter on legislative and policy essentials • Latest perspectives on auditory processing deficits

third edition

• Contemporary focus on student wellness and social competence • Expanded information and resources for access to general education • Updated perspectives on hearing loss prevention • New information on the development of remote audiology practices • Updated and more comprehensive technology information with multiple handouts and worksheets • Resources for students in all current learning environments • Expanded focus on coaching to support students and school staff

Cheryl DeConde Johnson, EdD, has an extensive history of advocacy for children and youth who are deaf and hard of hearing and their families. Through her many roles as an educational audiologist, early intervention specialist, deaf and hard of hearing program administrator, deaf education and audiology consultant with the Colorado Department of Education, author, and university instructor, she continues to provide consultation, program evaluation, and training globally through her practice, the ADE-vantage (Audiology Deaf Education). Cheryl is also a co-founder of Hands & Voices. She is most proud of her grown daughter who describes herself as sometimes deaf and sometimes hard of hearing and from whom Cheryl continues to be enlightened. Cheryl now shares her time between Leadville, Colorado, and Green Valley, Arizona. Jane B. Seaton, MS, consultant in audiology and communication disorders, has spent more than 40 years working with families and children with significant hearing and listening challenges. She developed and administered a model regional educational program for deaf and hard of hearing students and has professional experience in the field of pediatric and educational audiology in university, pubic health, hospital, and public school settings. Ms. Seaton received an undergraduate degree from Northwestern University, a Master’s degree from the University of Michigan, and continued her post-graduate education at the Universities of Akron, Washington, and Georgia. She has been an invited speaker and writer in the field of educational audiology and continues to serve as an early intervention specialist and stakeholder for Georgia’s Early Hearing Detection and Intervention program.

www.pluralpublishing.com

Educational Audiology Handbook

• Materials and recommendations to support interprofessional collaboration

Educational Audiology Handbook Cheryl DeConde Johnson _ Jane B. Seaton

third edition

Educational Audiology Handbook

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THIRD EDITION

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Editor-in-Chief for Audiology Brad A. Stach, PhD

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Educational Audiology Handbook

THIRD EDITION

CHERYL DECONDE JOHNSON, EDD      JANE B. SEATON, MS

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5521 Ruffin Road San Diego, CA 92123 e-mail: [email protected] Web site: https://www.pluralpublishing.com

Copyright © 2021 by Plural Publishing, Inc. Typeset in 10/12 Times LT Std by Achorn International Printed in the United States of America by Integrated Books International All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher. For permission to use material from this text, contact us by Telephone: (866) 758-7251 Fax: (888) 758-7255 e-mail: [email protected] Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publishers will gladly make the necessary arrangements at the first opportunity. Library of Congress Cataloging-in-Publication Data Names: Johnson, Cheryl DeConde, author. | Seaton, Jane B., author. Title: Educational audiology handbook / Cheryl DeConde Johnson, Jane B. Seaton. Description: Third edition. | San Diego, CA : Plural Publishing, Inc., [2021] | Includes bibliographical references and index. Identifiers: LCCN 2019051643 | ISBN 9781635501087 (paperback) | ISBN 9781635501094 (ebook) Subjects: MESH: Hearing Disorders | Child, Exceptional | Education of Hearing Disabled | School Health Services | Persons With Hearing Impairments | Audiologists | Professional Role Classification: LCC RF290 | NLM WV 271 | DDC 617.8—dc23 LC record available at https://lccn.loc.gov/2019051643

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Contents

List of Appendices  xv Preface xix Contributors xxiii

SECTION I

Educational Audiology Practices

CHAPTER 1

Legislative and Policy Essentials

3

Legislation and Policies  7 Key Legislation  8 Key Initiatives and Events in Deaf Education  16 Inclusion 16 The Deaf Child Bill of Rights  17 Early Hearing Detection and Intervention  17 The National Association of State Directors of Special Education  17 The Council for Exceptional Children, Division for Communication, Language, and Deaf/Hard of Hearing  18 Legislative Initiatives  18 Summary 18 Suggested Readings and Resources  19 Appendices  20

CHAPTER 2

Roles and Responsibilities of Educational Audiologists

31

Roles of Educational Audiologists  33 Educational Audiologists as Service Coordinators  33 Educational Audiologists as Instructional Team Members  34 Educational Audiologists as Consultants  34 Educational Audiologists in Schools for the Deaf  34 Responsibilities of Educational Audiologists  35 Identification 35 Assessment 37 Habilitation 37 Hearing Loss Prevention  38 Counseling and Coaching  38 Amplification, Cochlear Implants, and Other Assistive Technology  38 Ethical Considerations  39 Educational Audiology Service Delivery Models  39 School-Based Audiology Services  39 Contracted Audiology Services  40

v

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vi

Contents Combined School-Based and Contractual Agreement  41 Telepractice 41 Establishing and Expanding Educational Audiology Services in the Schools  42 Reimbursement for Educational Audiology Services  42 Dispensing Personal Hearing Instruments  42 Cerumen Management  43 Support for Early Hearing Detection and Intervention  43 Training for Educational Audiologists  44 Summary 45 Suggested Readings and Resources  45 Appendices  47

CHAPTER 3

Partnering With Families With Janet DesGeorges

57

Positive Attitudes  59 Rapport 59 Respect 59 Trust 60 Effective Communication  60 Informational Guidance  62 Quantity of Information  63 Types of Information  63 Parent-to-Parent Communication  65 Parent Involvement  66 Committee/Task Force Work  67 Classroom Support  67 Parent Activities  68 Difficult Situations  68 Parent/School Disagreement Over Individualized Education Program Services  69 Request for a Specific Brand of Amplification  69 Influence of Private Provider on School Services  69 Families That Have Difficulty Being Involved  70 Differing Opinions on Communication Modality  70 Summary 71 Suggested Readings and Resources  71 Appendices  72

CHAPTER 4

Hearing Screening and Identification

79

State Hearing Screening Mandates  81 Screening Requirements in Private Schools, Charter Schools, and Other Nontraditional Education Settings  82 Purposes of Hearing Screening and Identification Programs  82 Professional Guidelines  83 Age Considerations  83 Prevalence Considerations  84 Resources for Hearing Screening and Identification Programs  85 Personnel and Time  85 Scheduling Considerations  85

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Contents

vii

Screening and Identification Program Considerations  85 Early Childhood  85 School-Age Children and Youth  87 Screening and Identification Procedures  88 Visual Inspection  89 Auditory Brainstem Response  89 Otoacoustic Emissions  89 Pure-Tone Audiometry  90 Tympanometry 92 Behavioral Observation  93 Screening and Identification Protocols  93 Infants and Young Children  93 School-Age Children and Youth  93 Hearing Screening and Monitoring Children Who Cannot Respond to Traditional Measures  96 Screening Personnel  96 Audiologists 96 Speech-Language Pathologists  96 Parent Volunteers, School Nurses, and Paraprofessionals  97 Training of Support Personnel  97 Screening Equipment and Maintenance  97 Screening Equipment  97 Equipment Maintenance/Calibration  98 Infection Control  98 Screening Environment  99 Location of the Screening Room  99 Noise Levels  99 Other Factors  99 Organization of Screening and Identification Programs  99 Scheduling of the Screening  100 Activities Prior to the Screening  100 Activities During the Screening  100 Follow-Up Procedures  101 Follow-Up Screening for Middle Ear Conditions and Medical Referrals  101 Referrals for Audiological Evaluations  101 Educational Screening  101 Data Management and Reporting  102 Determining the Effectiveness of Hearing Screening and Identification Programs  102 Data from Screening Program  102 Sensitivity and Specificity  102 Cost Effectiveness  103 Summary 103 Suggested Readings and Resources  103 Appendices  104

CHAPTER 5

Assessment

111

The Cross-Check Principle in Educational Audiology  113 Basic Assessment of Hearing  113

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viii

Contents Case History  113 Otoscopy and Visual Inspection  114 Behavioral Assessment  114 Physiological Assessment  116 Modifications for Special Populations  118 Pure-Tone Modifications  118 Speech Modifications  120 Monitoring Hearing Sensitivity  121 Types of Monitoring  121 Schedules for Monitoring  121 Additional Audiometric Information and Functional Hearing Assessment  121 Speech Recognition for Sentences and Phrases  122 Speech Perception in Noise Testing  123 Listening in Noise  123 Speech Recognition With Visual Support  124 The Functional Listening Evaluation  124 Auditory and Listening Development Skills  125 Audiometric Assessment Considerations Without a Sound Booth  125 Cultural Considerations  125 Assessment of the Educational Effects of Hearing Status  127 The Classroom Listening Assessment  127 Use of T   eacher Checklists  128 Interpretation of Audiological Information  129 Need for Comprehensive Evaluation  130 Communication of Assessment Results  130 Audiograms 131 Written Reports  131 Teacher Letters  131 Letters to Physicians or Other Professionals  131 Telephone or Personal Conferences  132 E-mail, Texting, and Web-Based Communication  133 Documentation 133 Privacy Issues  133 Personal Vulnerability and Safety  133 Summary 135 Suggested Readings and Resources  135 Appendices  136

CHAPTER 6

Auditory Processing Deficits With Lisa R. Cannon 179 Auditory Processing Deficit Basics  181 Terminology and Definitions of Auditory Processing and Auditory Processing Deficits and Disorders  181 Criteria for Determination of an Auditory Processing Disorder  182 Practice Guidelines: The Role of the Audiologist and Other Professionals  182 APD and Other Disorders  183

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Contents

ix

An Educational Model of Auditory Processing  184 APD and Multitiered Systems of Support  184 Implementing a School-Based APD Program  185 Step 1. Developing the APD Team and Philosophy  185 Step 2. Referral and Screening  185 Step 3.  Assessment for APD  187 Step 4. Eligibility for Services  193 Step 5. Intervention  194 Summary 196 Suggested Readings and Resources  198 Appendices  199

CHAPTER 7

Classroom Acoustics and Other Learning Environment Considerations

219

Learning Environments and At-Risk Students  221 Listening and Learning Challenges  221 Lighting and Learning Challenges  223 At-Risk Students  224 Universal Design for Learning  224 Properties of Classroom Acoustics  226 Noise 226 Signal-to-Noise Ratio  226 Reverberation 226 Inverse Square Law and Critical Distance  227 Classroom Acoustics and Speech Perception  228 Effects of Noise on Speech Perception  228 Effects of Reverberation on Speech Perception  229 Combined Effects of Noise and Reverberation on Speech Perception  229 Effects of Classroom Acoustics on Teachers  229 Classroom Acoustics Standard  230 History and Development of the Standard  230 Current Standard Status  230 Classroom Audio Distribution Systems  231 Conformance and Tolerance Verification  231 Standard Adoption  231 Classroom Acoustics Resolutions and Guidelines  234 Measuring Classroom Acoustics  235 Classroom Observation  235 Instrumentation and Software Programs  236 Classroom Noise Measurements  236 Classroom Reverberation Measurements  236 Estimating Critical Distance  237 Role of the Educational Audiologist  237 Management of the Learning Environment  237 Summary 240 Suggested Readings and Resources  240 Appendices  242

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x

Contents

CHAPTER 8

Hearing Instruments and Remote Microphone Technology With Erin C. Schafer

255

Rationale for Hearing Instruments and Remote Microphone Technology  257 Recent Trends and Regulatory Considerations  257 Regulations 258 The Role of Case Law  258 Professional Practice Standards and Scope of Practice Considerations  258 The Responsibility of Public Education  260 Keeping Up with Technological Advancements  263 Equipment and Space Requirements  263 Assessment of Hearing Instrument and Remote Microphone Technology in Children and Youth  263 Candidacy and Candidacy Considerations  264 Device Selection Considerations for Remote Microphone Technology  265 Personal Hearing Instruments and Remote Microphone Technology Options  271 Hearing Aids  274 Cochlear Implants  275 Remote Microphone Technology  276 Implementation and Management of Hearing Technology  282 Fitting and V   erification  282 Orientation and Training  283 The Usage Plan  283 Validation 283 Monitoring and Equipment Management  284 Strategies to Implement the American Academy of Audiology Hearing Assistance Technology Guidelines  288 Other Assistive Technologies  291 Summary 291 Suggested Readings and Resources  291 Appendices  292

CHAPTER 9

Case Management and Habilitation

311

Planning Case Management and Habilitation  312 The Importance of Service Coordination  312 Facilitating Effective Case Management  313 Implementing Audiological Habilitation  314 Direct Services  314 Indirect Services  317 Services for Special Populations  323 Students With Unilateral Hearing Conditions, Single-Sided Deafness, or Minimal Hearing Loss  323 Students With Auditory Processing Deficits and Auditory Neuropathy Spectrum Disorder  324 Students With Multiple Learning Challenges  324 Students Using Cochlear Implants  325 Early Hearing Detection and Intervention  326 Inclusion 327 Summary 328 Suggested Readings and Resources  328 Appendices  330

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Contents

CHAPTER 10

Supporting Wellness and Social-Emotional Competence With Carrie Spangler

xi

363

A Wellness Perspective  365 Social-Emotional Development  367 Bullying and Victimization  370 Skills and Strategies for Students to Address Wellness and Social Competence  371 Self-Determination Skills  371 Self-Advocacy Skills  371 Counseling Strategies  375 Reflective Listening  376 Self-Assessment 376 Extending Conversations and Coaching  377 Networking for Students  377 Peer Mentors and Role Models  379 Referring for Additional Services  379 Summary 380 Suggested Reading  380 Appendices  381

CHAPTER 11

Developing Individual Plans

403

The Special Education Process  405 Step 1: Identification: Concern About the Child  406 Step 2: Referral to Special Education and Assessment  409 Step 3: Determination of Eligibility  410 Step 4:  The Individualized Education Program Meeting  414 Step 5: Review and Revision of the Individualized Education Program  416 Due Process Procedures  416 The Educational Audiologist’s Role in the Special Education Process  418 The Individualized Education Program  419 Consideration of Special Factors: Communication Considerations  421 Services, Placement, and Least Restrictive Environment Considerations  422 Services for Parents  422 Transition Planning  423 Individualized Education Program Goal Development  424 Section 504 Plan  426 The Services Plan  427 The Individual Family Service Plan  428 Eligibility Criteria  428 Purpose of the Individual Family Service Plan  429 Individual Family Service Plan Requirements  429 The Role of Case Law  431 Summary 431 Suggested Readings and Resources  431 Appendices  432

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xii

Contents

CHAPTER 12

Prevention of Noise-Induced Hearing Loss and Tinnitus in Youth With Deanna K. Meinke

447

Epidemiology Estimates of Noise-Induced Hearing Loss in Youth  448 Epidemiology of Noise-Induced Tinnitus in Youth  449 Rationale for Hearing Loss Prevention Targeting Youth  449 Public Health Role for Audiologists  451 Raising Public Awareness in the School Setting  451 Noise Awareness and Prevention Programs  451 Education to Prevent Noise-Induced Hearing Loss  452 Dangerous Decibels  453 Hearing Screenings for At-Risk Individuals  453 Advocating for Public Policies  454 Challenges and Future Directions  454

SECTION II Collaborative Practices and Program Effectiveness CHAPTER 13

Supporting the Educational Team With Carrie Spangler

459

Formal Inservice  461 Preparation 461 Presentation 465 Follow-Up 467 Continuing Contact With Participants  467 Coaching and Mentoring  468 Educational Coaching  468 Coaching for Educational Audiologists  469 Mentoring 470 Summary 470 Suggested Readings and Resources  470 Appendices  472

CHAPTER 14

Educational Considerations for Students Who Are Deaf or Hard of Hearing

481

Critical Issues in Deaf Education  483 Accountability and Oversight  483 Communication and Communication Access  484 Quality Instruction  485 Evidenced-Based Practices  487 Students Not Eligible for Special Education  488 Maintaining Teacher of the Deaf and Related Service Provider Positions  488 Parent and Family Engagement  488 Early Hearing Detection and Intervention and Early Childhood Education  489 Technology 489 Deaf V   ersus Hard of Hearing  489 National Association of State Directors of Special Education:  Ten Essential Principles for Effective Education of Deaf and Hard of Hearing Students  490 What Is Research Saying?  491

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xiii

Legislative Initiatives in Deaf Education  492 Language Acquisition and Literacy Accountability  492 Deaf Child’s Bill of Rights  492 Hearing Aid Insurance  493 Educational Assessment  493 Transition Planning  494 Best Practice Considerations for Educating Children and Youth Who Are Deaf or Hard of Hearing  495 Know Your Students  495 Adopt Program Standards  496 Conduct a Program Review  496 Identify Evidence-Based and Consensus-Based Practices  496 Utilize Progress Monitoring  497 Incorporate Expanded Core Curricula  497 Utilize Deaf and Hard of Hearing Peers and Role Models  497 Engage Parents and Caregivers  497 Summary 500 Suggested Reading  500 Appendices  501

CHAPTER 15

Collaborative School–Community Partnerships

519

Establishing and Maintaining Relations With Community Resources  521 Identifying and Interfacing With Community Resources  521 Identifying Resources Through a Community Survey  521 Potential Community Partners  522 Updating the Community Resource Survey  525 Marketing and Advocacy for Educational Audiology Programs  525 Increased Name Recognition  526 Broadened Visibility of Services  526 Increased Knowledge of Program Outcomes  526 Internal Marketing  526 External Marketing  527 Developing and Fostering Creative Collaborative Efforts  527 Information and Materials to Share  527 Facilitating Interprofessional Collaboration  530 Fostering Creative Community Collaboration  532 Legal and Ethical Issues  534 Summary 534 Suggested Readings and Resources  535 Appendices 536

CHAPTER 16

Program Development, Evaluation, and Management

551

Program Development  553 Laying the Foundation  553 Needs Assessment  554 Planning 555

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Contents Program Evaluation  558 Assessment of Existing Audiology Services  558 Planning for Improvement  562 Implementation of New Services  562 Measuring Effectiveness  563 State Model Evaluation Systems  564 Program Management  566 Annual and Monthly Scheduling  566 Day-to-Day Scheduling  566 Office Support  566 Data Management  568 Forms 568 Budget and Finances  568 Facilitating Meetings  568 Challenges 568 Summary 570 Suggested Reading and Resources  570 Appendices 571

CHAPTER 17

Reflections and Future Directions With Sarah Florence

575

Emerging Themes  576 The Educational Audiologist as an Integral Member of the Multidisciplinary Team  576 The Emphasis on Accountability, Specific Student and Program Outcomes, and Use of Cost-Effective Strategies to Address Critical Issues  576 Societal Factors  577 Promoting Hearing Loss Prevention as a Social Health Problem  577 Remote Audiology Services  577 Remote Educational Audiology Services Model  577 Remote/Onsite Hybrid Model  578 Remote Support of Onsite Educational Audiologists  578 Service Considerations  578 Remote Technology Tools  578 Summary 579

References 581 Index 595

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List of Appendices

1.

2.

3.

4.

5.

Legislative and Policy Essentials 1–A

 omparison of Pertinent Areas of the Individuals With Disabilities Education Act (IDEA) Part B, C Section 504, and the Americans With Disabilities Act (ADA) (Text)  20

1–B

 omparison of Pertinent Part B and Part C Individuals With Disabilities Education Act (IDEA) C Requirements Related to Children and Youth Who Are Deaf or Hard of Hearing (Text)  23

1–C

Summary of Laws Pertaining to Persons Who Are Deaf or Hard of Hearing (Text/Online)  29

1–D

 ey Individuals with Disabilities Education Act (IDEA) Regulations Pertaining to Audiology and K Deaf Education Services (Online)

Roles and Responsibilities of Educational Audiologists 2–A

Educational Audiology Association: Supporting Students who are Deaf and Hard of Hearing: Shared and Suggested Roles of Educational Audiologists, Teachers of the Deaf and Hard of Hearing, and Speech-Language Pathologists, Checklist (Text/Online)  47

2–B

Part C Roles of Audiologists in Early Hearing Detection and Intervention (Text)  51

2–C

Educational Audiology Association: Educational Audiology Scope of Practice (Text)  53

Partnering With Families 3–A

Resources for Parents of Children Who Are Deaf or Hard of Hearing (Text/Online)  72

3–B

Family Needs Interview for Families of Children Who Are Deaf or Hard of Hearing (Text/Online)  75

3–C

Childhood Hearing Loss Question Prompt List for Parents (Text/Online)  77

Hearing Screening and Identification 4–A

State Hearing Screening Laws for Children in Schools (Text)  104

4–B

HEAR Checklist (Text/Online)  109

4–C

Record of Ear and Hearing Problems (Online)

4–D

Basic Hearing Problems Questionnaire for Students With Developmental Delays (Text/Online)  110

4–E

Preparation Checklist for Preschool and School Hearing Screening (Online)

4–F

Parent Notification Letter for Hearing Screening (Online)

4–G

Class Hearing Screening Results Record Forms (Online)

4–H

School Hearing Rescreening/Referral List (Online)

4–I

Sample Teacher Notification of Screening Results (Online)

4–J

Sample Parent Notification of Screening Results—Pass (Online)

4–K

Sample Parent Notification of Screening Results—Recheck (Online)

4–L

Sample Parent Letter to Refer Child for Further Audiological Evaluation (Online)

4–M

Sample Medical Referral Letter and Return Medical Referral Form (Online)

4–N

Sample Medical Referral Form (Physician) (Online)

Assessment 5–A

Audiology Case History (Text/Online)  136

5–B

Familiar Sounds Audiogram (Text/Online)  138

5–C

Sample Audiogram (Text/Online)  139

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6.

7.

8.

List of Appendices 5–D

Word Recognition in Quiet and Noise for Normally Developing Children (Text)  142

5–E

Speech Audibility Audiogram for Classroom Listening (Text/Online)  143

5–F

Adaptations for Assessing Children/Youth Who Are Blind/Visually Impaired (Text/Online) 144

5–G

Common Functional Outcome Measures for Listening Performance (Text)  146

5–H

The Functional Listening Evaluation (Text/Online)  150

5–I

Classroom Participation Questionnaire—Revised (Text/Online)  155

5–J

Auditory Problems Self-Checklist (Text/Online)   160

5–K

Relationship of Hearing Loss to Listening and Learning Needs (Text/Online)  161

5–L

 ichigan Department of Education—Low Incidence Outreach Educational Impact M Matrix for Students Who Are Deaf or Hard of Hearing (Text/Online)  170

5–M

General Teacher Letter (Text/Online)  174

5–N

Ordering Information for Selected Assessment Products (Text)  177

Auditory Processing Deficits 6–A

Auditory Processing Deficit Screening Questionnaires (Text/Online)  199

6–B

Referral for Auditory Processing Assessment (Text/Online)  201

6–C

Auditory Processing Case History (Text/Online)  202

6–D

Auditory Processing Assessment Resources (Text)  205

6–E

Supplemental and Multidisciplinary Tests of Auditory Processing (Text)  207

6–F

Auditory Processing Assessment Profile (Text/Online)  210

6–G

Accommodations and Modifications Checklist for Auditory Processing Deficits (Text/Online)  212

6–H

Computer-Based Auditory Training Programs (Text)  214

6–I

Instructional Interventions for Students With Auditory Processing Deficits (Text/Online)  216

6–J

A Multitiered Model of Auditory Processing Deficit Interventions (Text)  218

Classroom Acoustics and Other Learning Environment Considerations 7–A

Classroom Acoustics Screening Survey Worksheet (Text/Online)  242

7–B

 sing the Student, Environments, Tasks, and Tools Framework to Identify Assistive Technology U and Interpreting Services for Students Who Are Deaf or Hard of Hearing (Text/Online)  248

7–C

Resources (Text)  250

Hearing Instruments and Remote Microphone Technology 8–A

Student Amplification Listening Evaluation (Text/Online)  292

8–B

Pediatric Amplification Listening Evaluation (Text/Online)  295

8–C

Personal Amplification Monitoring Plan (Text/Online)  299

8–D

Instructions for Hearing Aid Checks (Online) 

8–E

Instructions for Cochlear Implant Checks (Online)

8–F

Instructions for Osseointegrated Bone Conduction Implant Checks (Online)

8–G

Instructions for Personal Remote Microphone System Checks (Online)

8–H

Hearing Technology Monitoring Chart (Online)

8–I

The Ling Six Sound Check (Text/Online)  300

8–J

Tips to Enhance Remote Microphone Use (Text/Online)  302

8–K

 emote Microphone Hearing Assistance Technology Implementation R Worksheet: In-School Form (Text/Online)  303

8–L

 emote Microphone Hearing Assistance Technology Implementation Worksheet: R Out-of-School Form (Text/Online)  307

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List of Appendices

9.

10.

11.

Case Management and Habilitation 9–A

Form to Facilitate Collaboration Between Teacher/School Provider and Physician (Text/Online)  330

9–B

Auditory and Tactile Assessment and Curricula (Text)  331

9–C

Listening Development Profile (Text/Online)  332

9–D

Teaching Strategies and Classroom Activities for Selected Listening Difficulties (Text)  335

9–E

Parent Letter on Speechreading (Text/Online)  338

9–F

Speechreading Resources for Children (Text)  339

9–G

Classroom-at-a-Glance: Observation Checklist (Text/Online)  340

9–H

Reduced Hearing and Recorded Speech (Text/Online)  342

9–I

Functional Auditory Performance Indicators (FAPI) (Text/Online)  343

9–J

Language and Communication (Text/Online)  359

9–K

Early Auditory Skill Development for Special Populations (Text/Online)  360

9–L

Auditory Response Data Sheet (Text/Online)  362

Supporting Wellness and Social-Emotional Competence 10–A

Self-Determined Learning Model of Instruction (Text/Online)  381

10–B

Resources for Social-Emotional Development and Social Competence (Text)  383

10–C

Student Accommodations Notification Templates (Text/Online)  386

10–D

Hearing Notification Card (Online)

10–E

 udiology Self-Advocacy Checklists (Teacher Forms) and “I Can” A Self-Advocacy Checklist (Student Form) (Text/Online)  390

10–F

Overview of Ida Counseling Tools for Children, Youth, and Young Adults (Text)  396

10–G

Ten Tools for Developing Self-Efficacy With Hearing Loss (Text/Online)  398

10–H

Guide to Setting Up Student Support Groups (Text/Online)  400

Developing Individual Plans 11–A

I ndividualized Education Program/Section 504 Checklist: Accommodations and Modifications for Students Who Are Deaf or Hard of Hearing (Text/Online) 432

11–B

Individualized Education Program Team Responsibilities for the Educational Audiologist (Text/Online)  434

11–C

Communication Considerations Worksheet (Text/Online)  435

11–D

PARC: Placement and Readiness Checklists for Students Who Are Deaf or Hard of Hearing (Online) ■■ ■■ ■■ ■■ ■■ ■■ ■■

13.

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xvii

General Education Inclusion Readiness Checklist Interpreted/Transliterated Education Readiness Checklist Captioning/Transcribing Readiness Checklist Oral + Manual Instruction Access Checklist Placement Checklist for Children Who Are Deaf or Hard of Hearing: Preschool/Kindergarten Placement Checklist for Students Who Are Deaf or Hard of Hearing: Elementary Placement Checklist for Students Who Are Deaf or Hard of Hearing: Secondary

11–E

Checklist for ADA Services (Text/Online)  438

11–F

Sample Section 504 Plan (Text/Online)  439

11–G

Case Law Summary (Text)  441

Supporting the Educational Team 13–A

Inservice Outlines (Text)  472

13–B

Inservice and Hearing Simulation Resources (Text)  476

13–C

Sample Index Card Handouts (Text/Online)  478

13–D

Inservice Evaluation Form (Text/Online)  479

13–E

Sample Coaching Concept Organizer (Text)  480

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14.

15.

16.

List of Appendices

Educational Considerations for Students Who Are Deaf or Hard of Hearing 14–A

Colorado Individualized Education Program Communication Plan (Text /Online)  501

14–B

Assessment Terminology (Text)  503

14–C

Summary of Psychoeducational, Language, and Communication Assessments (Text)  505

14–D

 ational Association of State Directors of Special Education (NASDSE) Implementation: Deaf N and Hard of Hearing Program and Service Review Checklist (Text/Online)  512

Collaborative School–Community Partnerships 15–A

Sample Community Resource Survey Form (Text/Online)  536

15–B

Service Clubs That Support Programs for Persons With Disabilities (Text)  538

15–C

Sample Cover Letter to Community Resources (Text/Online)  539

15–D

Community Education and Marketing Resources (Text)  540

15–E

School and Community Survey of Educational Audiology Services (Text/Online)  542

15–F

Sample Survey: Educational Audiology Services (Text/Online)  544

15–G

Marketing/Advocacy Outcomes Log (Text/Online)  545

15–H

EARS—School Contract Template (Text)  546

15–I

Implant Center/School/Therapist/Parent Information Exchange Form (Text/Online)  547

15–J

Characteristics That Foster Successful Collaboration (Text)  549

Program Development, Evaluation, and Management 16–A

Self-Assessment: Effectiveness Indicators for Audiology Services in the School (Online)

16–B

Goal Prioritization Worksheet (Online)

16–C

Long-Range Planning Form (Online)

16–D

Logic Model Planning Form (Online)

16–E1

Educational Audiology Workload Analysis Form (Text)

16–F

Recommended Outcomes and Evidence for Educational Audiology Tier 1 Services (Text)  573

571

Instructional Materials (Online) Basic Syllabus Chapter Learning Objectives Chapter PowerPoint Slides Chapter Discussion Questions

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Preface

It has been 22 years since the first edition of the Educational Audiology Handbook was published and eight years since the second edition. We are older, not sure if we are wiser, but we hope to have threaded throughout this third edition traditional practices with additional evolving practices that we feel are necessary to strengthen educational audiology services. As in the past, this handbook focuses on the practice of audiology within the educational environment. We recognize that audiology practice settings, job descriptions, and employment conditions vary from state to state and district to district. However, we believe that educational audiologists are indispensable. In order to fulfill our role as advocates for students, educational audiologists should be consistent and participatory members of the multidisciplinary team whether that is in-person and/or remote. As a member of the team, responsibilities should be discussed and shared to ensure all relevant and necessary services are provided, particularly those related to access to communication and learning in the classroom.

New and Updated Content This edition of the handbook includes information on legislation, and guidelines and procedures for educational audiologists and related professionals serving deaf and hard of hearing students in all learning environments. We are grateful to our contributing authors who have offered new perspectives on the topics of family partnerships (Janet DesGeorges), auditory processing deficits (Lisa Cannon), remote microphone technologies (Erin Schafer), wellness and social competence and support for the educational team (Carrie Spangler), prevention of noise-induced hearing loss (Deanna Meinke), and tele-audiology practice (Sarah Florence). In addition, Krista Yuskow, among others, have provided practical nuggets for everyday application of various components of educational audiology services. Look for this icon throughout the text indicating Nuggets from the Field:    Overall, we have tried to emphasize the importance of improving outcomes for all children with auditory deficits, particularly with the increasing diversity in student demographics, performance, and learning environments. We also hope to move the focus on disability or deficits to wellness and promote a positive perspective of hearing and processing “differences” in order to align with school efforts to promote social-emotional well-being in all students. We believe that our students’ identities, self-

esteem, and self-determination skills are all precursors to becoming effective self-advocates. While we recognize that it is the right of each person to determine how they would like their hearing status referenced (e.g., deaf, hard of hearing, hearing impaired, hearing loss), we have used terminology that refers to hearing levels or differences rather than “losses” whenever possible and appropriate. Lastly, we are very excited to endorse remote audiology services. We think some form of this model is in the future of most every educational audiologist’s practice.

Handbook Use Considerations The number of printed appendices (and the length of the book) has been reduced by moving forms and some protocols and handouts to the online PluralPlus companion website. Many of the online forms have been formatted so that you can modify them to add your logo or school information. Materials available on the companion website are noted in the Table of Contents and Chapter Contents. The handbook also has many links to resources at other websites. We guarantee that they all worked at the time of production. However, URLs change frequently, and we know this is frustrating. If a link does not work, try entering the first part of the link to get to the desired entity’s home page and then search for a document.

Support for Educational Audiology Coursework A new feature of this Handbook edition is that it is designed to serve as a textbook for educational audiology and other related coursework. The companion website contains a basic syllabus, and learning objectives, discussion questions, and PowerPoint slides for each chapter. We hope to provide students in AuD and other related programs (speech-language pathology, deaf education) with an appreciation for the practice of audiology in educational settings as well as the importance of teamwork and parent involvement when serving students who are deaf or hard of hearing.

Acknowledgments In addition to our author contributors, we would like to recognize the students who contributed chapter page artwork. They are: xix

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xx

Preface

Allison, Mogadore, OH Anec, Edmonton, Alberta, CA Ben, Athens, GA Billy, Mogadore, OH Jaxen, Denver, CO Nikayla, Edmonton, Alberta, CA Sara Madeleine, Colorado Springs, CO Sophia, Greeley, CO Izabela, Justin, Rupert, Katie, & Emmy, Ohio high school students Finally, we would like to acknowledge the spirit and work of all audiologists, especially those who devote their careers to working in the schools. The politics and resource limitations in education are challenging and require our constant vigilance. However, the gratification of working with students, parents, teachers, and other school professionals, and our ability to be involved in the lives of the children for such a critical part of their development yields countless rewards; perhaps why so many of us remain in our positions throughout our careers. We close with the following remarks, taken from the Educational Audiology Association Listserve, in response to a query for reasons to motivate graduate students in audiology about careers in educational audiology. They describe why we love what we do. “LOVE my job . . . nothing better than watching a kid do well and knowing you had a part in it. I don’t get summers off  .  .  .  but I still LOVE my job  .  .  .  even after 24 years and lots of admin headaches and parent pains . . . . .” “There will be headaches with any job. What I can tell you is that working with kids in schools is so rewarding over time. You may not realize day to day the impact you can have on a child’s life but you will and you will find out as they grow and flourish and succeed. . . . and later in your life, some of those very kids will find you and tell you that. . . . . and when that happens, any challenge I have had with a parent or an administrator just melts away. . . .” “I just came in contact less, than 2 weeks ago, with a 36-year-old hearing-impaired guy who is now a counselor for the deaf and hard of hearing. . . . . I saw his name on his office door. . . . . . it was the same ‘little boy’ I had worked with in the preschool deaf program from 1975–1978. . . . . . . wow, what a feeling. So, unless you can search inside yourself and find a really great reason to not work in the schools with kids, then do it!!” “As an educational audiologist for 20 some years, I wasn’t really all that surprised to hear the words, ‘Can you believe I get paid to do this?,’, come out of my mouth as I was working with an AuD intern!” “The job is SO rewarding and offers complete job satisfaction overall. I truly believe the pros far outweigh the

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cons! The connections you make are long lasting and you learn a great deal along the way about the impact of hearing loss on the lives of children and families. I say give it a go . . . it is definitely worth trying!” “27 years and counting. I love this career although there are days I don’t like the ‘job’ very much. Every job has plus and minuses but I wouldn’t trade the irritations in this position for any other one! I took the leap after working in the medical side of things since 1999. I now work in the 0–5 program including the preschool. I often would call my mom or a friend for months after starting having to talk about how much I love my job! I am sure they were sick of hearing it. I also share space with the 2 audiologists that work in the public schools and work closely with 2 university audiologists. We all have sat and talked about how lucky we were to have landed our gigs! Go for it, it is so worth it professionally and personally.” “There are headaches, frustrations, and challenges, but the rewards of seeing the impact of what you do in the lives of both the child/family and in the school environment . . . is worth every minute. I have worked in many different roles as an audiologist (clinical, private practice, early intervention, and now in education) and I have no regrets. I love my job and hope to be here for many years to come. I think back to grad school when Kris English told me I would be an educational audiologist and I told her, “I don’t think so!” Looking back (several years later), I remember the phone call to Kris after I moved here and started as an educational audiologist admitting, “OK, you were right . . . this is exactly where I should be. (Thanks Kris)” “I have been an audiologist with an ENT, an audiologist with a non-profit speech and hearing center, and now an audiologist in a large school district. My favorite has been the school setting . . . hands down! I enjoy the challenges, the interaction with the kids, and the camaraderie within the special education department. And I cannot tell a lie . . . I enjoy these summers with my own kids!!” “I am a dual certified/licensed, SLP/A. I worked in the public school arena for 34 years spending 1/2 time doing SLP and 1/2 time doing Ed Aud stuff. I retired from the school district five years ago and they kept me on, on a consulting basis, to continue to function as the Ed Aud for however long they will tolerate me. Despite the ups and downs, I wouldn’t trade those 34 years for anything. And now, I still love my time ‘in district’ once per week. Of course, I don’t tell that to the Special Ed. Director because I need to maintain an aura of independence. Headaches and fighting with parents and administrators come with any job in our related fields. It’s up to you to “educate and demonstrate” (stolen from a rather well-known stuttering officionado in NYC) to the

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Preface

uninitiated, in a way that produces the best results for our hearing-impaired charges, and results in optimal outcomes.” “For me educational audiology has always been about the opportunity to learn as much as I can about pediatric hearing loss impact across a broad spectrum of domains, which hopefully has in turn helped me to

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do my job better. If you feel a sense of frustration in a standard clinical setting because you are locked out of knowing the middle and end of the pediatric ‘story,’ then educational audiology is for you.”

Cheryl DeConde Johnson and Jane Seaton November, 2019

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Contributors

Lisa R. Cannon, AuD, CCC-A Educational Audiologist, Denver Public Schools Audiology Coordinator, Colorado Department of Education Denver, Colorado Chapter 6 Janet DesGeorges Executive Director, Hands & Voices Boulder, Colorado Chapter 3 Sarah Florence, AuD Educational Audiology Coordinator, University of North Texas Educational Audiology Consultant: Onsite and Remote Services Conifer, Colorado Chapter 17 Deanna K. Meinke, PhD, CCC-A Professor Audiology and Speech-Language Sciences University of Northern Colorado Co-Director of Dangerous Decibels Greeley, Colorado Chapter 12

Erin C. Schafer, PhD Associate Professor Department of Audiology and Speech-Language Pathology University of North Texas Denton, Texas Chapter 8 Carrie Spangler, AuD, CCC-A Lead Educational Audiologist Summit Educational Service Center Cuyahoga Falls, Ohio Chapters 10 & 13 Krista Yuskow, AuD, R. Aud Educational Audiology Consultant Inclusive Learning–Edmonton Public Schools Edmonton and Wood Buffalo Regional Collaborative Service Delivery University of Alberta, Guest Lecturer Edmonton, Alberta Chapter Nuggets and Student Artwork

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SECTION I

EDUCATIONAL AUDIOLOGY PRACTICES

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CHAPTER

1

Chapter 1

Legislative and Policy Essentials CONTENTS Key Legislation Legislation and Policies Key Initiatives and Events in Deaf Education Inclusion ■ The Deaf Child Bill of Rights ■ Early Hearing Detection and Intervention ■ The National Association of State Directors of Special Education ■ The Council for Exceptional Children, Division for Communication, Language, and Deaf/Hard of Hearing ■ Legislative Initiatives

“Lisn Pls” to what I need to hear in my classroom.

3

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Chapter 1

CONTENTS 

(Continued )

Chapter 1

Summary Suggested Readings and Resources Appendices 1–A Comparison of Pertinent Areas of the Individuals With Disabilities Education Act (IDEA) Part B, Section 504, and the Americans With Disabilities Act (ADA) (Text) 1–B Comparison of Pertinent Part B and Part C Individuals With Disabilities Education Act (IDEA) Requirements Related to Children and Youth Who Are Deaf or Hard of Hearing (Text) 1–C Summary of Laws Pertaining to Persons Who Are Deaf or Hard of Hearing (Text/Online) 1–D Key Individuals With Disabilities Education Act (IDEA) Regulations Pertaining to Audiology and Deaf Education Services (Online)

KEY  TERMS Statutes, regulations, Individuals with Disabilities Education Act (IDEA), Section 504, Americans with Disabilities Act (ADA), effective communication under ADA, accommodations, modifications, equal access, special communication factors

■■

■■

KEY POINTS ■■

■■

A growing number of students with reduced hearing and other auditory deficits are not being served through special education. To staff school audiology services at the American Speech-Language-Hearing Association (ASHA) and Educational Audiology Association (EAA) recommended level of one audiologist for every 10,000 students, 3,785 more audiologists are needed in the schools.

The first definition of Educational Audiology was proposed by Berg and Fletcher in 1976 as an outcome of the 1965 Babbidge Report: Educational audiology seeks to isolate the parameters of hearing impairment, to identify the deficiencies rising from hearing disabilities, to relate these to the unique characteristics of individuals, and to develop educational programs specifically for hardof-hearing children. (Berg, 1976, p. 30)

■■

Major limitations of the Individuals with Disabilities Education Act (IDEA) are that individual states have a great deal of latitude in their interpretation of the provisions and that the federal government lacks significant consequences in its accountability system. All students with reduced hearing or other auditory disorders must be represented on the Individualized Education Program (IEP) team by a specialist in hearing/ deafness. (“specialist” may be defined by each state’s plan but is usually a teacher of deaf and hard of hearing students, an audiologist, or sometimes a speechlanguage pathologist who can interpret test results and make appropriate recommendations.) While many students have more opportunity because of the increased accountability, additional legislation, and other education initiatives of the past decade, there is still much work to do to ensure the required and recommended practices are implemented at the local school level in the intended manner.

Educational audiology represents one of the most challenging yet rewarding practice areas of our profession. The challenge is in reconciling the sheer numbers of children and their diverse needs with sufficient audiology full-time equivalent (FTE) positions, support, equipment, and resources to meet those needs. The reward is the opportunity to make a difference in children’s lives every day. What are some of the challenges facing audiologists in educational settings? ■■

A large in-school population—about 50,580,000 children prekindergarten through grade 12 in the United States based on 2016 enrollment data reported by the National Center for Education Statistics (https://nces .ed.gov/programs/digest/d17/tables/dt17_201.10.asp).

4

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5

Legislative and Policy Essentials

■■

A large out-of-school population including children who are birth through age 2 years, children attending community-based preschools, and students who are incarcerated or in special facilities. From these populations, children with reduced hearing must be identified, and appropriate services must be provided. A growing number of students with reduced hearing and other auditory deficits who are not served through

■■

special education. These students are in general education classrooms and often do not have Section 504 plans or other formally identified accommodations. Many unserved students that did not meet eligibility for services under the Individuals with Disabilities Education Act (IDEA) when they transitioned from early intervention and thus lack monitoring or follow-up until they have difficulty or fail in general education programs.

Chapter 1

■■

TABLE 1–1  Number of Full-Time Equivalent Audiologists Employed by States and Audiologist-to-Student Ratios During the 1991–1992, 2006–2007, and 2016–2017 School Years 1991–1992 FTE Audiologists1

2006–2007 FTE Audiologists2

2016–2017 FTE Audiologists3

2016–2017 Audiologist to Student Ratio

Alabama

8

21

10.66

1:69,034

Alaska

4

3

5.9

1:22,525

Arizona

16

63

47.83

1:23,561

Arkansas

4

4

2.85

1:172,737

California

51

198

124.41

1:50,440

Colorado

31

54

58.8

1:15,480

Connecticut

15

No data

No data

Delaware

2

13

12

1:11,433

D.C.

4

3

2

1:43,150

Florida

47

60

54.5

1:51,719

Georgia

39

26

36.4

1:48,755

Hawaii

3

1

1

1:188,500

Idaho

10

4

3.62

1:80,967

Illinois

48

36

31.64

1:64,434

Indiana

14

15

21.6

1:48,153

Iowa

58

50

42.51

1:12,000

Kansas

19

22

23.12

1:21,648

Kentucky

4

7

5

1:139,200

Louisiana

15

22

20

1:36,184

Maine

11

24

Maryland

25

29

State

Massachusetts

9.86 32.1

1:18,124 1:27,763

7

5.86

1:162,270

Michigan

20

14

21.66

1:69,474

Minnesota

26

52

37.32

1:23,395 (Continues )

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6

Chapter 1

TABLE 1–1  (Continued )

State Mississippi

1991–1992 FTE Audiologists1

2006–2007 FTE Audiologists2

2016–2017 FTE Audiologists3

Chapter 1

9

1

Missouri

13

16

Montana

4

4

2.83

1:51,767

Nebraska

3

7

3.22

1:98,851

Nevada

3

6

7.52

1:62,633

New Hampshire

1

3

.91

1:197,473

New Jersey

44

51

35.2

1:39,347

New Mexico

21

35

18.11

1:18,758

New York

21

105

118.46

1:23,231

North Carolina

32

77

73.41

1:21,409

North Dakota

3

4

26

93

4

5

Oregon

64

16

14.05

1:43,324

Pennsylvania

25

40

76.32

1:22,543

Rhode Island

2

0

South Carolina

17

13

15.75

1:49,041

South Dakota

3

4

.82

1:165,366

Tennessee

32

22

24.35

1:41,035

Texas

21

40

63.5

1:84,740

Utah

22

26

26.68

1: 24,561

2

5

1.86

1:45,860

127

66

45.7

1:28,330

Washington

0

28

29.53

1:37,071

West Virginia

5

8

7.2

1:38,736

Wisconsin

12

19

24.35

1:35,639

Wyoming

8

5

3.25

1:29,662

BIA

1

12

4.2

999

1439

1272.8

1:34,271

1:39,733

Ohio Oklahoma

Vermont Virginia

Total Audiologist-to-Student Ratio4

1:42,173

4.87

2016–2017 Audiologist to Student Ratio

11.6

2

1:100,103 1:78,931

1:56,300

39.47 6

1:43,276 1:116,200

1

1:140,700

1

  U.S. Department of Education (1994b). Sixteenth Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act, p. A-212.   http://www.ideadata.org, Table C-1 (Estimated Resident Population Ages 6–17 years, 2008) and Table 3–5, Audiologists Employed to Serve Children and Students ages 3–21 Under IDEA, Part B, Fall 2006). 3   U.S. Department of Education. 40th Annual Report to Congress on the Implementation of the Individuals with Disabilities Education Act. Exhibit 45: Number of full-time (FTE) personnel to provide related services for children and students ages 3 to 21 served under IDEA, Part B (state audiology FTE provided by OSEP to author 5.7.19). 4   Based on Pre-K to 12th-grade enrollment, National Center for Educational Statistics (https://nces.ed.gov). 2

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Legislative and Policy Essentials

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School districts that often do not know about students with reduced hearing unless they have Individualized Education Programs (IEPs). Therefore, these students often must “fail” before their hearing status is revealed or connected to their learning problems. The education system is often “failing” these students and leaving them behind. An alarming shortage of educational audiologists to pro­ vide services to these students. As shown in Table 1–1, 1,273 full-time equivalent (FTE) audiologists were reported as employed in school settings in the United States in the Fall of 2016, representing an average ratio of one audiologist for every 39,733 children. By comparison, there were 999 FTE audiologists reported during the 1991 to 1992 school year, yielding a ratio of 1:42,173 (U.S. Department of Education, 1994b). To staff school audiology services at the American Speech-LanguageHearing Association (ASHA) and Educational Audi­ ology Association (EAA) recommended level of one audiologist for every 10,000 students, 3,785 more audiologists are needed in the schools. General and special education administrators who often have limited, if any, knowledge about listening and communication access needs of children in learning environments. Limited financial resources to provide necessary hearing assistance technology and services for each child with hearing and listening needs. Limited time to conduct audiology services as stipulated in state and federal regulations (IDEA, 2004) including ensuring consistent and effective communication access (ADA, 2008). A federal law that is interpreted by each state, resulting in services and programs that differ significantly across state lines. These services also may vary within states, depending on the individual school district’s understanding, commitment, and willingness to provide audiology services. Adaptation of a traditionally clinical model of audiology to one that is functional, meaningful, and responsive to children and youth within the educational environment.

LEGISLATION AND POLICIES Key events, policies, and legislation that have impacted audiology and the education of deaf and hard of hearing children are summarized in Table 1–2.1 A basic understanding of the legislative process is necessary to utilize pertinent laws appropriately to ensure the rights of all persons with disabilities. Statutes and their accompanying regulations passed by the federal government usually result in state legislation to ensure that state laws align with federal policy.

Understanding Statutes and Regulations Statutes are laws passed by Congress (at the federal level) and state and local legislatures. These laws are often termed “Acts” and, at the federal level, are numbered according to the Congress within which they are passed (e.g., PL 94-142 was the 142nd public law enacted by the 94th Congress). These Acts are periodically reauthorized, often with amendments and name changes. At the federal level, the Acts are first published in the Statutes at Large, after which they are organized by subject in the United States Code (U.S.C.). The U.S.C. has 50 subject classifications called Titles in which the laws are further indexed and assigned section numbers. Title 20 is the section for education. Example: The Individuals with Disabilities Education Act (IDEA) is published in the U.S.C. as 20 U.S.C. §1400, et seq., meaning that it is in Title 20 of the U.S.C. beginning with Section 1400 (“et seq.” is a Latin abbreviation and legal term indicating the writer is citing a page and the pages that follow). Regulations clarify and explain the United States Code. The responsible agency (e.g., the Department of Education) must publish the proposed regulations in the Federal Register to solicit comment from the public. Following revision, the final regulations are then published in the Code of Federal Regulations (C.F.R.). IDEA is published in Vol­ ume 34, Part 300 of the Code of Federal Regulations, referred to as 34 CFR §300. There are numerous sections and subsections. Within the final published regulations, commentary is included that responds to the proposed regulations comments. This commentary explains the rationale for terms, definitions, and requirements of the final rules and is very helpful when interpreting various components of the regulations.

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Although legislation should define public policy, ensuring that individual rights are protected, services are provided, and a level of quality is maintained, it does not guarantee that sufficient funds are provided or that compliance is adequately enforced. Advocacy groups have played a major role in the interpretation and monitoring of legislative actions. The area of special education, having some of the most active, productive, and influential public and professional advocacy groups in the United States, is an excellent

1

 Historical events beginning in the 1960s that were chronicled in early editions of this text.

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Chapter 1

TABLE 1–2  Key Policies and Events Impacting the Education of Children Who Are Deaf or Hard of Hearing in the United States from the 1960s to the Present Legislation: Non-Special Education

Legislation/Policy: Special Education

1960s

Events, Reports, and Publications Joint Committee on Audiology and Education of the Deaf (1965) The Babbidge Report (1965)

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1970s

Section 504 of the Rehabilitation Act of 1973

PL 93-380, the Education of the Handicapped Amendments of 1974 PL 94-142, Education for all Handicapped Children Act (1975)

1980s

PL 100-553 established the National Institute on Deafness and Other Communication Disorders at the National Institutes of Health (1988)

PL 99-457, Education of the Handicapped Act Amendments (EHA) of 1986

National Commission on Excellence in Education: A Nation at Risk (1983) Commission on Education of the Deaf: Toward Equality: Education of the Deaf (1988)

1990s

PL 101-336, Americans with Disabilities Act (1990) PL 103-227, Educate America Act, 1994 (Goals 2000)

PL 101-476, Individuals with Disabilities Education Act (IDEA) (1990) PL 105-17, Individuals with Disabilities Education Act (IDEA) (1997)

U.S. Department of Education Notice of Policy Guidance (October 1992) Council of Organizational Representatives’ proposal for a Deaf Child Bill of Rights (1992) National Association of State Directors of Special Education (NASDSE): Deaf and Hard of Hearing Students: Education Service Guidelines (1994) The National Deaf Education Project (1998)

2000–2009

PL 107-110, No Child Left Behind (NCLB) (2001) PL 110-325, Americans with Disabilities Act Amendments Act (2008)

PL 108-446, Individuals with Disabilities Education Improvement Act, (2004)

The National Agenda (2005) National State Leaders Summit (2005–2011) National Association of State Directors of Special Education (NASDSE): Meeting the Needs of Students who are Deaf or Hard of Hearing Students: Education Service Guidelines, 2nd ed. (2006)

2010–2020

Every Student Succeeds Act 2015

U.S. Department of Justice, U.S. Department of Education (2014). Dear Colleague Letter on Effective Communication

Pepnet 2 Building State Capacity Summit Series (2011–2016) National Association of State Directors of Special Education (NASDSE): Optimizing Outcomes for Students who are Deaf or Hard of Hearing: Educational Service Guidelines, 3rd ed. (2018)

example of how public policy can be influenced by groups heralding a common cause.

Key Legislation The primary education law that delineates U.S. public school requirements is titled the Elementary and Secondary Education Act (ESEA), first passed in 1965. This law

Plural_Johnson_Ch01.indd 8

has been reauthorized under different names; for example, “No Child Left Behind” (NCLB) in 2001, followed by the “Every Student Succeeds Act” (ESSA) in 2015. NCLB was the first time that specific provisions were made for the inclusion of children with disabilities in the state performance and accountability systems in states. Among the various laws passed affecting special education, three are the most significant:

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Legislative and Policy Essentials

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Section 504 of the Rehabilitation Act of 1973; the Individuals with Disabilities Education Act (reauthorized and amended numerous times since its inception in 1975 as PL 94-142); and the Americans with Disabilities Act (ADA), passed in 1990, and its amendments.

With time the lines between these laws and their regulations have blurred. However, together they provide comprehensive protection to all children whether or not they are identified as disabled under the special education statutes. Appendix 1–A summarizes the key features of each law. Specific components that differentiate these laws include the following. Title II of ADA and Section 504 are both civil rights laws; Section 504 prohibits discrimination in entities that received federal financial assistance while ADA prohibits discrimination in any state or local government entity regardless of federal financial assistance. A Section 504 plan directly applies to a student’s services and accommodations, while the ADA requires equal access for all individuals within these entities who may be experiencing difficulties connected to broader definitions of disabilities, including students who qualify for services under IDEA. IDEA eligibility requires the existence of a disability (as identified in the IDEA, Part B regulations2) that adversely affects educational performance necessitating special education and related services. It is the need for specialized instruction that distinguishes IDEA from the services provided under Section 504. Section 504’s broader definition also includes persons with disabilities3 not mentioned in IDEA or state education policies. Furthermore, mitigating measures, that is how well a child performs with a hearing aid or cochlear implant or when a sign language interpreter is provided, cannot be used to mitigate disability determination. Appendix 1-C summarizes basic elements of each of these pertinent laws. ■■

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Regarding IDEA, Section 504 regulations state: “A free appropriate public education is the provision of regular education or special education and related services that . . . are designed to meet individual educational needs of persons with disabilities as adequately as the needs of persons without disabilities are met.”4 Therefore, the obligation to provide appropriate education may extend beyond the traditional special education programs. Because a school district is obligated to provide services (evaluations, general education, reasonable accommodations, related services, and related aids) regardless of eligibility for special education under IDEA, the school district may be bound to use general education funds to provide related services and/or aids for a child with disabilities.

Specially Designed Instruction Specially designed instruction means adapting, as appropriate to the needs of an eligible child under this part, the content, methodology, or delivery of instruction (i)  To address the unique needs of the child that result from the child’s disability; and (ii) To ensure access of the child to the general curriculum, so that the child can meet the educational standards within the jurisdiction of the public agency that apply to all children. (34 CFR §300.39(b)(3))

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Simply because a child with a disability under IDEA receives a free and appropriate education (FAPE) through a school district’s special education program does not necessarily mean that the situation is in compliance with Section 504 or ADA. IDEA provides a program designed to meet the unique needs of a child and related services to assist the child to benefit from special education,5 while ADA provides the right to effective communication access “equal to” nondisabled peers, a higher standard than is required under IDEA.

Section 504 of the Rehabilitation Act of 1973 This act is commonly referred to as the civil rights legislation for people with disabilities because it was the first law that specifically protected the rights of persons with disabilities by prohibiting recipients of federal funds from discriminating against “otherwise qualified individuals” (34 CFR §104). The provisions of this law are almost identical to the nondiscriminatory provisions related to race in Title VI of the Civil Rights Act of 1964 and to gender in Title IX of the Education Amendments of 1972. Section 504 prohibits entities that receive federal financial assistance from discriminating based on disability, ensuring that students with disabilities are provided an equal opportunity to access and participate in or benefit from the aid, benefits, services, and opportunities provided to others in federally assisted programs. This Act defines a disability as: “any person who (1) has a physical or mental impairment that substantially limits a major life activity; (2) has a record of such an impairment; or (3) is regarded as having such an impairment.”6

2

34 CFR §300.5. Individuals with physical or mental impairments that substantially limit one or more major life activities or record of such impairment or regarded as having such impairment. 4 34 CFR §104.33(b)(1). 3

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5

34 C.F.R §300.39 and §300.34. 29 U.S.C. §705(9)(B), (20)(B).

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Chapter 1

TABLE 1–3  Patterns of Services for Students Who Are Deaf or Hard of Hearing Percentage of Students With an Individualized Education Program

Percentage of Students With a 504 Plan

Percentage of Students Without a Service Plan

Colorado (2005)

43

2

55

Washington (2012)

57

17

26

Iowa (2012)

54

No data available

46

77% DHH; 12% DHH dual diagnosis; 50% EC (20% DHH, 30% other)

2%

9%/20% (EC)

State

Minnesota (2019)

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Note. From personal communications: Colorado, June 1, 2005; Washington, August 5, 2012; Iowa, October 4, 2012; Minnesota, June 24, 2019.

The impact of Section 504 for students with disabilities continues to grow as more students receive support services under this law. Data from the Departments of Education in Colorado, Washington, Iowa, and Minnesota reveal patterns of service provision for students who are deaf or hard of hearing (Table 1–3). Students whose disabilities do not meet IDEA eligibility criteria but who do require communication access or other assistance benefit from Section 504 plans. Comprehensive assessment is required prior to eligibility determination to ensure that students would not benefit from “specialized instruction” (i.e., the distinguishing feature between services under IDEA and Section 504). As previously stated, The ADA Amendments Act of 2008 expanded the interpretation of disability to align definitions between ADA and Section 504. In addition to the broadened definition of “major life activities” (see text box), Section 504 eligibility determination must be made without the effects of mitigating measures. These measures include hearing aids, medications, and other learned behavioral adaptations such as tutoring. Therefore, a child who wears hearing aids to access classroom communications, who receives private tutoring to maintain A and B grades or receives extensive homework help is still eligible as a student with a disability under Section 504. Two groups for which this law has significant implications are children with minimal, mild, and unilateral hearing loss, single-sided deafness, and children with auditory processing difficulties. For these groups, acoustic accessi-

Major life activities may include but are not limited to caring for one’s self, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working.

Plural_Johnson_Ch01.indd 10

bility is an invisible barrier to their hearing, listening, and/ or understanding of auditory information. These students typically are overlooked unless knowledgeable audiologists, teachers, parents, or other individuals represent their needs in schools. Amplification systems and other classroom and communication accommodations are critical general education supports that can be implemented for students to provide accessibility without special education eligibility (see Chapter 11, Developing Individual Plans, for more information on Section 504, and Chapter 9, Case Management and Habilitation, for additional information about student support needs and services). The Office of Civil Rights at the U.S. Department of Education provides comprehensive guidance regarding students with disabilities and Section 504, Protecting Students with Disabilities (https://www2 .ed.gov/about/offices/list/ocr/504faq.html?exp=0).

The Americans With Disabilities Act (ADA) The ADA was enacted in 1990 to provide protection from discrimination based on disability, just as the 1964 Civil Rights Act prohibited discrimination based on race, sex, creed, and national origin. Modeled after the Rehabilitation Act of 1973, the ADA replaced the word “handicap” with “disability” and pertains to all employers, facilities, and services, not just those receiving federal funds. Covered disabilities include physical conditions affecting mobility, stamina, sight, hearing, and speech as well as conditions such as emotional illness and learning disorders (see text box). The Act includes five sections (called Titles) covering employment, public services and transportation, public accommodations and commercial facilities, telecommunications, and miscellaneous provisions. Title II of the Act pertains to public schools, institutions of higher education, vocational education, and public libraries. It does not apply to schools of medicine, dentistry, nursing, and other healthrelated schools (these are covered under Title III). The ADA was amended in 2008 (ADA Amendments Act) providing an expanded interpretation of disability. The disability requirements of ADA for schools are the same as Section 504 of the Rehabilitation Act of 1973. Thus, the expanded definition

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Legislative and Policy Essentials

ADA Checklist (Johnson, 2014)

IDEA provides reasonable access to public education through individualized services regardless of costs, administrative burden, or programming required. Title II of ADA requires that the services are not only accessible, but that they provide effective communication that is equal to that of nondisabled persons, so long as they do not impose an undue burden or require a fundamental alteration of their programs.

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Chapter 1

  Does the student meet disability criteria under ADA?   Does the student attend a public preschool, elementary, or secondary school (including charter schools and magnet programs)?   Does the student require auxiliary aids and services to achieve communication that is as effective as communication for individuals without disabilities?   Are the auxiliary aids and services provided by the school based on an appropriate assessment and analysis in accordance with

of disability likely resulted in an increase in the number of Section 504 plans whose needs may have been previously handled under health care plans. The Access Board (short for the Architectural and Transportation Barriers Compliance Board) was created by the Rehabilitation Act of 1973 as an independent federal agency devoted to accessibility for people with disabilities by ensuring access to federally funded facilities. The Board is now a leading source of information on accessible design and provides technical assistance and training on accessible design, including classroom acoustics, as well as general ADA requirements. The Board continues to enforce accessibility standards that address federally funded facilities, most recently the Information and Communication Technology (ICT) Standards and Guidelines7 in 2018. Effective Communication under the ADA  The U.S. Department of Justice and U.S. Department of Education together published a policy guidance, Frequently Asked Questions on Effective Communication for Students With Hearing, Vision, or Speech Disabilities in Public Elementary and Secondary Schools (2014), to address obligations of schools to provide these services (https://www2.ed.gov /about/offices/list/ocr/docs/dcl-faqs-effective-communication -201411.pdf). This guidance describes eligibility and accom­ modations under Title II of the Americans with Disabilities Act (ADA) and the Individuals with Disabilities Education Act (IDEA) as well as important differences between the laws. The ADA Checklist (see text box and Appendix 11–E) summarizes some of the key communication access considerations required under Title II of ADA. Timelines for implementing ADA accommodations create some interesting challenges. For example, to use a remote microphone system, do we wait for IDEA eligibility and the IEP to use IDEA funds or fit immediately as required under ADA and provide through general school funds. The implications of this policy clarification may be the most significant development since the inclusion of special

11

the method of communication used by the individual; the nature, length, and complexity of the communication involved; and the context in which the communication is taking place?

  Are the auxiliary aids and services provided by the school primarily based on the preferences of the student, or his/her parents/guardian, with disabilities?   Are the auxiliary aids and services provided in a timely manner?   Are the auxiliary aids and services provided in such a way as to protect the privacy and independence of the student?

factors to the IEP toward “leveling the playing field” for children and youth who are deaf or hard of hearing.

Individuals With Disabilities Education Act (IDEA) The primary legislation for children with disabilities was first passed in 1975 as PL 94-142. This law stated that “All children who are handicapped and in need of special education and related services must be identified, evaluated, and assured a free appropriate public education in the least restrictive environment” (Rules and Regulations, U.S. Department of Health, Education, and Welfare, August 23, 1977). Although there have been several reauthorizations of this law since, the major principles remain the same. These principles are summarized in Table 1–4. Key changes from each reauthorization include the following: ■■

1986: expansion to ages 3 to 5 and the addition of Part C to address services for birth to age 3;

7

36 CFR §1193 & §1194.

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12

Chapter 1

TABLE 1–4  Major Principles of PL 94-142/Individuals With Disabilities Education Act (IDEA) Full educational opportunity (zero reject)

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Identification

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Multidisciplinary evaluation

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Individualized Education Program (IEP)

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Least restrictive environment (LRE)

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Procedural safeguards and due process

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Requires that all children with disabilities be provided with a free and appropriate public education (FAPE) Requires a child find program to locate, identify, and evaluate all children who are suspected of having a disability who live in the jurisdiction of each public agency Requires a full, individual, comprehensive evaluation before placement in a special education program Evaluation must be multidisciplinary and meet specified standards, and interpretation must consider information from a variety of sources Development and implementation of the IEP ensures that educational programs are determined on an individual basis to meet the needs of students with disabilities IEP requirements specify the content, scope, timeliness for writing IEPs; participants in the IEP meeting; parent participation; private school placements; and accountability Placement of children occurs so that, to the maximum possible, children with disabilities are educated with their typical peers Removal to special classes occurs only when the nature or severity of a child’s disability prevents successful education in general education classes even with the use of supplementary aids and services A continuum of alternative education services from more restrictive to less restrictive is provided by the public agency Placement decisions are determined by the goals and objectives of the student’s IEP and are reviewed annually Establishes and implements regulations, standards, and procedures for compliance with all procedural safeguards, including written notice to parents of referral, confidentiality of information, rights to independent educational evaluation, parental consent for placement, due process hearings, and appointment of surrogate parents when needed Ensures fairness of educational decisions and the accountability for making decisions for both professionals and parents

1990: changed “handicapped” to “disabilities,” added assistive technology devices and services; and 1997: added consideration of special factors, assistive technology use in the home when needed to receive FAPE, parent training.

services and as part of assistive technology. Considering multiple sources of input, Congress responded by excluding mapping services in the statute. Because the proposed regulations were found to be ambiguous, the Office of Special Education Programs of the U.S. Department of Education responded in the final regulations with language clearly defining its intentions. Although schools are exempt from “optimizing” cochlear implant functioning, including mapping and maintaining or replacing these devices, schools are required to continue to provide other services as determined by the IEP team. These include other related services such as speechlanguage therapy, support for the child’s communication development, and routine monitoring of cochlear implants to make sure they are functioning properly. 2. Routine Checking of Hearing Aids and Cochlear Implants9 School systems have always been required to ensure that hearing aids worn by children in school are func-

The most recent reauthorization of IDEA, the Individuals With Disabilities Education Improvement Act (still referred to as IDEA), PL 108-446, was passed in 2004. Selected highlights pertaining to students who are deaf or hard of hearing are summarized in the following list. Implications of these regulations are discussed in greater depth in the chapters that correspond with the topic areas. 1. Cochlear Implants8 Prior to the 2004 statute, there had been a growing number of legal decisions requiring school districts to provide mapping (programming) services for children’s cochlear implants as an audiology service under related 8

34 CFR §300.34[b]; 34 CFR §303.12.

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9

34 CFR §300.113.

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3.

4.

5.

6.

7.

tioning properly. The new regulations changed the previous wording from shall ensure to must ensure, adding some subtle strength to the requirement. In addition, a new section was added that specifically addresses cochlear implants (see earlier). It requires schools to ensure that the external components of the cochlear implant are working properly (see Appendix 11–G, Detroit City School District—Michigan State Education Agency 15-00085 [2015]). Assistive Technology Used at Home10 The IEP team may determine that a child needs to use his or her assistive technology (e.g., remote microphone system) at home or in other settings outside of school to meet IEP goals. This regulation is particularly pertinent with preschool children who may attend school for only 3 or 4 half-days per week yet participate in other language and learning opportunities throughout the day. Interpreting Services11 As an official related service, interpreting includes oral and cued speech transliteration, sign language interpreting, note taking and computerized transcription services (e.g., Communication Access Real-time Translation [CART], C-Print, TypeWell). Although it is unclear how the highly qualified requirements of IDEA have impacted interpreters, ADA provides for effective communication, meaning that communication access must be as effective through interpreting as a student who does not require accommodations. Eligibility for Services12 Eligibility for special education and related services does not require a child to fail. Section 300.101(c) states “each state must assure that FAPE is available to any individual child with a disability who needs special education and related services even though the child has not failed or been retained in a course and is advancing from grade to grade.” Consideration of Special Factors13 First added in the 1997 IDEA amendments, this regulation requires access to communication with peers and professional personnel in the student’s communication or language mode. Although a subtle wording change from “the IEP team shall consider” to “must consider,” this regulation is the heart of the IEP for deaf or hard of hearing students. IEP teams must document how each provision of this section is determined. Transition Services14 The definition of transition services emphasizes a “results oriented process” aimed at improving “the academic and functional achievement that facilitates the

student’s movement from school to postschool activities, including postsecondary education, vocational education, integrated employment, continuing and adult education, adult services, independent living, or community participation” (34 CFR §300.43(a)). The IEP requirements were modified requiring IEPs for youths 16 years and older to contain appropriate postsecondary goals as well as the transition services needed to assist youths to achieve those goals. 8. Response to Intervention (RTI)15 Also referred to as a Multi-Tiered System of Support (MTSS), the RTI/MTSS framework provides a schoolwide approach to address the needs of all students, including students who are struggling learners and students with disabilities. Generally, students are served through this framework prior to initiation of a special education referral to ensure that the learning problem is not a result of lack of appropriate instruction. The MTSS framework is considered to have a broader scope than RTI to focus on the entire education system to set high expectations for all students. These RTI procedures are not intended to delay or deny initial evaluations for children suspected of having a disability (OSEP, 2011) and therefore may not be an appropriate process for students with sensory, cognitive, or physical disabilities. However, the RTI principles do have components that potentially benefit instruction for all children in the general education classroom. These include access to high-quality instruction (scientifically, research-based interventions) matched to individual needs, frequent monitoring procedures to identify how children are responding to these interventions, and use of child response data to inform educational decisions. Read more about RTI/MTSS in Chapter 6, Auditory Processing Deficits; Chapter 11, Developing Individual Plans; and Chapter 14, Education Considerations for Students Who Are Deaf or Hard of Hearing. Despite efforts to change terminology, the definitions pertaining to hearing impairment and audiology services have remained unchanged. Definitions of hearing impairment are explained in three categories: ■■

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34 CFR §33. 105[a][2]. 34 CFR §300.34[c][4]. 12 34 CFR §300.101. 13 34 CFR §300.324[2][iv]. 14 34 CFR §300.43 and §300.320 [b][2]. 11

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Legislative and Policy Essentials

“Deaf-blindness” means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness. “Deafness” means a hearing impairment that is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification, that adversely affects a child’s educational performance.

15

34 CFR §300.307, 309.

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“Hearing impairment” means an impairment in hearing, whether permanent or fluctuating, that adversely affects a child’s educational performance but that is not included under the definition of deafness in this section.16

Chapter 1

Figure 1–1 summarizes key definitions for audiology and deaf education including the Part B and Part C definitions of audiology (subtle differences between them are underlined). Appendix 1-B compares pertinent sections of Part B and Part C regulations and Appendix 1-D contains a one page handout of relevant regulations pertaining to audiology and education of deaf or hard of hearing students. In addition, audiologists are included as one of several “qualified personnel” for providing early intervention services. A controversial audiology service under Part C is the dispensing of amplification devices. In most states Part C is a community-based service managed under agencies other than departments of education. Therefore, if hearing aids or other amplification devices are necessary for a child, it may be a community or healthcare responsibility to determine how they are provided to the family. While Part C stipulates that services are provided at no cost, hearing aids, cochlear implants, and bone conduction devices are generally the responsibility of the parents. Because insurance typically has not covered hearing aids (although related surgical procedures for implantable devices are covered by most plans), several states have now passed legislation requiring insurance coverage for hearing aids. Many states and communities also have loaner banks and other programs that will provide hearing aids when other resources are not available. The National Center for Hearing Assessment and Management (NCHAM) (http://www.infanthearing.org) maintains a list of state loaner hearing aid banks. Pertinent sections of the current rules and regulations for IDEA Parts B and C (2004) are contained in Appendix 1–B. For deaf and hard of hearing students, the most significant changes to IDEA since its inception occurred with the addition of “special factors” as part of the development, review, and revision of the IEP.17 Each IEP team must consider the following special factors: ■■

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communication needs of the child and in the case of a child who is deaf or hard of hearing, consider the child’s language and communication needs; opportunities for direct communications with peers and professional personnel in the child’s language and communication mode; academic level; and full range of needs, including: ……

16 17

opportunities for direct instruction in the child’s language and communication mode and

……

requirements for assistive technology devices and services.

This provision addresses the importance of language and communication access for deaf and hard of hearing students. Although this regulation should be the core of the IEP for students with reduced hearing, IEP meetings often default to a checklist rather than having discussion regarding the full meaning and the associated consequences for each student. Communication considerations are discussed further in Chapter 11, Developing Individual Plans. Major limitations of IDEA are that individual states have a great deal of latitude in their interpretation of the provisions and that the federal government lacks significant consequences in its accountability system. Furthermore, performance data that pertains to students with lowincidence disabilities such as hearing impairment/deafness tend to draw little attention in the monitoring process and, as a result, are often overlooked, or compiled with other low-incidence disability data. These problems contribute to the variability in services that exists among states. A review of litigation related to special education law can be found in Appendix 11–G. These cases demonstrate the power of the court system in interpreting regulations and consequently providing clarification to procedures and services. Following a general societal pattern, the reliance on the court system to define IDEA and civil rights for children continues to escalate. Unfortunately, litigation requires parents who have the time, money, and perseverance to take on their local school programs. In addition, such litigation may not be in the best interests of the involved children because their parents are often pitted against their school systems in bitter disputes rather than working together for the children. Although 2004 IDEA regulations helped reduce frivolous cases by placing the responsibility of paying for legal fees on the parent if a decision rules against them, parents find that the legal process is often their only recourse in a dispute. IDEA now generally requires mediation as a first step for resolving problems. Because the IEP is the key to ensuring that appropriate services are provided for deaf and hard of hearing students, it is imperative that their IEPs be developed by individuals knowledgeable about the specific communication and educational needs of these students. Therefore, all students with reduced hearing or other auditory disorders must be represented on the IEP team by a specialist in hearing/deafness. (“Specialist” may be defined by each state’s plan but is usually a teacher of deaf or hard of hearing students, an audiologist, or sometimes a speech-language pathologist who can interpret test results and make appropriate recommendations.) To be effective, educational audiologists need to understand their role in the IEP process. This role is discussed in Chapter 11, Developing Individual Plans.

34 CFR § 300.7, 34 CFR § 300.8[b]. 34 CFR §300.324[a].

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Legislative and Policy Essentials

15

IDEA 2004 Key Regulations Pertaining to Audiology and Deaf Education Exception; services that apply to children with surgically implanted devices, including cochlear implants. (1) Related services do not include a medical device that is surgically implanted, the optimization of that device’s functioning (e.g., mapping), maintenance of that device, or the replacement of that device. (2) Nothing in paragraph (b)(1) of this section— (i) Limits the right of a child with a surgically implanted device (e.g., cochlear implant) to receive related services (as listed in paragraph (a) of this section) that are determined by the IEP Team to be necessary for the child to receive FAPE. (ii) Limits the responsibility of a public agency to appropriately monitor and maintain medical devices that are needed to maintain the health and safety of the child, including breathing, nutrition, or operation of other bodily functions, while the child is transported to and from school or is at school; or (iii) Prevents the routine checking of an external component of a surgically-implanted device to make sure it is functioning properly, as required in §300.113(b).

PART C DEFINITION OF AUDIOLOGY 34CFR303.13(b)(2) (2011)

Audiology services includes(i) Identification of children with auditory impairments, using at risk criteria and appropriate audiological screening techniques; (ii) Determination of the range, nature, and degree of hearing loss and communication functions, by use of audiologic evaluation procedures; (iii) Referral for medical and other services necessary for the habilitation or rehabilitation of an infant or toddler with a disability who has an auditory impairment; (iv) Provision of auditory training, aural rehabilitation, speech reading and listening devices, orientation and training, and other services; (v) Provision of services for the prevention of hearing loss; and (vi) Determination of the child's need for individual amplification, including selecting, fitting, and dispensing of appropriate listening and vibrotactile devices, and evaluating the effectiveness of those devices.

PART B - DEFINITION OF AUDIOLOGY 34CFR300.34(c)(1)

Audiology includes(i) Identification of children with hearing loss; (ii) Determination of the range, nature, and degree of hearing loss, including referral for medical or other professional attention for the habilitation of hearing; (iii) Provision of habilitation activities, such as language habilitation, auditory training, speech reading, (lipreading), hearing evaluation, and speech conservation; (iv) Creation and administration of programs for prevention of hearing loss; (v) Counseling and guidance of children, parents, and teachers regarding hearing loss; and (vi) Determination of children’s needs for group and individual amplification, selecting and fitting an appropriate aid, and evaluating the effectiveness of amplification.

PART B INTERPRETING SERVICES 34CFR300.34(c)(4)

Interpreting services includes(i) The following when used with respect to children who are deaf or hard of hearing: oral transliteration services, cued language transliteration services, and sign language transliteration and interpreting services, and transcription services, such as communication access real-time translation (CART), C-Print, and TypeWell; and (ii) Special interpreting services for children who are deaf-blind.

ASSISTIVE TECHNOLOGY 300.105(a)(2)

On a case-by-case basis, the use of school-purchased assistive technology devices in a child’s home or in other settings is required if the child’s IEP Team determines that the child needs access to those devices in order to receive FAPE.

Prepared by Cheryl DeConde Johnson, Ed.D., The ADEvantage. (2011)

PART B ROUTINE CHECKING OF HEARING AIDS AND EXTERNAL COMPONENTS OF SURGICALLY IMPLANTED MEDICAL DEVICES 34CFR300.113

(a) Hearing aids. Each public agency must ensure that hearing aids worn in school by children with hearing impairments, including deafness, are functioning properly. (b) External components of surgically implanted medical devices. (1) Subject to paragraph (b)(2) of this section, each public agency must ensure that the external components of surgically implanted medical devices are functioning properly. (2) For a child with a surgically implanted medical device who is receiving special education and related services under this part, a public agency is not responsible for the post-surgical maintenance, programming, or replacement of the medical device that has been surgically implanted (or of an external component of the surgically implanted medical device).

Chapter 1

PART B RELATED SERVICES 34CFR300.34(b)

PART B DEVELOPMENT, REVIEW, AND REVISION OF IEP, Consideration of special factors 34CFR300.324(2)(iv)

The IEP Team must(iv) Consider the communication needs of the child, and in the case of a child who is deaf or hard of hearing, consider the child’s language and communication needs, opportunities for direct communications with peers and professional personnel in the child’s language and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the child’s language and communication mode; (v) Consider whether the child needs assistive technology devices and services.

ASSISTIVE TECHNOLOGY PART B 34CFR300.5-.6 & PART C 34CFR303.13(b)(1)(i)

Assistive technology device means any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of children with disabilities. The term does not include a medical device that is surgically implanted, or the replacement of such device. Assistive technology service means any service that directly assists a child with a disability in the selection, acquisition, or use of an assistive technology device. The term includes(a) The evaluation of the needs of a child with a disability, including a functional evaluation of the child in the child’s customary environment; (b) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices by children with disabilities; (c) Selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices; (d) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs; (e) Training or technical assistance for a child with a disability or, if appropriate, that child’s family; and (f) Training or technical assistance for professionals (including individuals providing education or rehabilitation services), employers, or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of children with disabilities.

PART B DEFINITIONS 34CFR300.8(c)

[2] Deaf-blindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness. [3] Deafness means a hearing impairment that is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification that adversely affects a child’s educational performance. [5] Hearing impairment means an impairment in hearing, whether permanent or fluctuating, that adversely affects a child’s educational performance but that is not included under the definition of deafness in this section.

FIGURE 1–1  Key IDEA regulations pertaining to audiology and deaf education services. (Compiled by Cheryl DeConde Johnson, EdD, The ADEvantage, 2011.)

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16

Chapter 1

The Rowley Case

Chapter 1

The first case decided by the U.S. Supreme Court involving PL 94-142 involved the use of a sign language interpreter by a deaf student in a mainstreamed classroom. In the 1982 case, Hendrick Hudson School District Board of Education v. Rowley, the Supreme Court overturned previous District Court and Court of Appeals decisions that had interpreted “appropriate” to mean “to maximize the potential of each handicapped child commensurate with the opportunity provided nonhandicapped children.” In the Supreme Court’s ruling on this case, “appropriate education” was defined as a program that provides “personalized instruction with sufficient support services to permit the child to benefit educationally from that instruction. . . . In addition, the IEP, and therefore the personalized instruction, should be formulated in accordance with the requirements of the Act, and if the child is being educated in the regular classrooms of the public education system, should be reasonably calculated to enable the child to achieve passing marks and advance from grade to grade.” By ruling that the school did not have to provide a sign language interpreter for the main-

KEY INITIATIVES AND EVENTS IN DEAF EDUCATION

stream placement because the student was performing well without an interpreter even though she missed a substantial portion of what was being said in class, the court brought forth the argument of minimum versus maximum services. The ruling emphasized that the intention of FAPE was not to maximize the child’s education program but rather to provide access to a program that is sufficient to confer some educational benefit.The dissenting opinion of the Supreme Court, however, emphasized that PL 94-142 guaranteed an equal educational opportunity and that the basic floor of opportunity intended to eliminate the effects of the handicap, at least to the extent that the child will be given an equal opportunity to learn, and that passing grades alone should not be the basis for that opportunity.The meaning of “appropriate education” continues to be one of the most litigated areas of IDEA, and sometimes the impact of the litigation does find its way into regulations. For example, the 2004 IDEA regulations specify that passing grades cannot be used as a criterion to deny FAPE. (See Chapter 11 for more discussion on current FAPE and eligibility regulations.)

Inclusion has changed the face of special education since the 1990s. Up to this time, many students with disabilities received the majority of their education outside of the general education classroom in resource rooms for students in special education. Students were mainstreamed into general education classrooms when the IEP team determined that they could benefit from the general education curriculum. In contrast, inclusion places students with disabilities in the general educational classroom as members of the class as their typical peers. They are served in either push-in (within the regular classroom) or pull-out models, typically separated only when specific instruction or therapy cannot occur within the student’s classroom. Least restrictive environment (LRE) is the term used by IDEA rather than inclusion. LRE requires that students with disabilities are to be educated in the regular classroom to the maximum extent possible and that removal from the regular education environment occurs “only if the nature of severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily.”17

As time has passed, inclusion has impacted all students with disabilities under the tenet of LRE. Although many students are benefiting from their education in the regular classroom, the actual benefit derived from the general classroom setting by some students with disabilities remains controversial. Many school districts now only have separate classrooms for students with the most severe behavior problems or very limited cognitive function. Therefore, most deaf and hard of hearing students are educated in general education classrooms relying on a consulting or itinerant teacher of the deaf/hard of hearing in combination with access technologies and educational interpreters across the country. The use of Special Factors18 is critical to ensure appropriate opportunities and services are provided. Educational audiology has been significantly impacted by the increased inclusion of children with auditory, language, and learning problems in general education classrooms. With fewer students educated in small groups in resource rooms that can be controlled for noise and distance from the speaker, auditory learning problems have escalated. In addition to children with reduced hearing, audiologists are fitting hearing assistance technology on children with normal hearing who have other language and/or learning problems to counteract the effects of noise and distance listening problems. These issues are discussed further in Chapter 7, Classroom Acoustics

17 

18 

Inclusion

34 CFR § 300.114 (a)(2)(i)(ii).

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34 CFR § 300.324[2][iv].

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Legislative and Policy Essentials

According to the 40th Annual Report to Congress (U.S. Department of Education, 2018), 76.8% of deaf or hard of hearing students with IEPs receive 40% or more of their education in the regular classroom.

and Other Learning Environment Considerations; Chapter 8, Hearing Instruments and Remote Microphone Technology; and Chapter 11, Developing Individual Plans.

The Deaf Child Bill of Rights The movement for a bill of rights for deaf and hard of hearing children emanated from the 1988 Commission on Education of the Deaf (COED) report, the 1992 U.S. Department of Education Policy Guidance, and the 1992 Council of Organizational Representatives’ (COR) proposal for a Deaf Child Bill of Rights. Without federal legislation, several states have enacted legislation containing many of the components of the COR-proposed Bill of Rights. Other states have adopted comparable policies through their state departments of education, and still others have proposed legislation that did not pass or are in the process of developing legislation. Regardless of the means, these efforts have generally resulted in a Communication Plan that expands on the requirements of IDEA’s Consideration of Special Factors. Chapter 14, Education Considerations for Students Who are Deaf or Hard of Hearing, provides more information regarding Communication Plans.

Early Hearing Detection and Intervention Much of the improvement in educational outcomes of deaf and hard of hearing children can be attributed to early hearing detection and early intervention programs. Beginning with the Walsh Bill in 1999, the Newborn and Infant Hearing Screening and Intervention Act, most current national and state early hearing detection and intervention (EHDI) activities are supported by the NCHAM, a technical assistance center funded by the Maternal and Child Health Bureau of the Health Resources and Services Administration (HRSA) at the U.S. Department of Health and Human Services. The goal of NCHAM is “to ensure that all infants and toddlers with hearing loss are identified as early as possible and provided with timely and appropriate audiology, educational, and medical intervention.” NCHAM’s research, training, and technical assistance activities contribute to this goal by working to achieve the following objectives: ■■

Every child born with a hearing loss is identified before 3 months of age and provided with timely and appropriate intervention by 6 months of age.

Plural_Johnson_Ch01.indd 17

■■ ■■

Every family of an infant with hearing loss receives culturally competent family support as desired. All newborns have a “medical home.” State Departments of Health have effective newborn hear­ ing screening tracking and data management systems which are linked with other relevant public health information systems.” (http://www.infanthearing.org/about/)

The National Association of State Directors of Special Education The National Association of State Directors of Special Education (NASDSE) published the first edition of the Educational Service Guidelines for deaf and hard of hearing students in 1994, followed by a second edition in 2006. This document has provided comprehensive information about necessary components of programming for deaf and hard of hearing (DHH) students to states and school programs througout the United States. The third edition, Optimizing Outcomes for Students who are Deaf or Hard of Hearing: Educational Service Guidelines (2018), continues to provide current recommended practices regarding administration, early identification and intervention, evaluation and eligibility, services and placement, school access accommodations, postsecondary transition, and personnel. Chapter 1 identifies 12 essential principles that are necessary to understand and optimize the education of deaf and hard of hearing students. This edition includes a services review checklist to review local services in relation to the recommended practices (see Appendix 14–D). The guidelines may be downloaded free from http://www.nasdse.org.

Chapter 1

■■

17

Essential Principles to Optimize the Education of Deaf and Hard of Hearing Students (NASDSE, 2018) ■■ ■■

■■ ■■

■■ ■■

■■

■■

■■

■■

Each student is unique. High expectations drive educational programming and future employment opportunities. Families are critical partners. Early language development is critical to cognition, literacy, and academic achievement. Specially designed instruction is individualized. Least restrictive environment (LRE) is student based. Educational progress must be carefully monitored. Access to peers and adults who are deaf or hard of hearing is critical. Qualified providers are critical to a child’s success. State leadership and collaboration is essential.

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18

Chapter 1

The Council for Exceptional Children, Division for Communication, Language, and Deaf/Hard of Hearing

Chapter 1

The Division for Communication, Language, and Deaf/ Hard of Hearing under the Council for Exceptional Children (CEC-DCD) has published guidance documents including a position statement describing the critical need for teachers of the deaf/hard of hearing, Teachers of Students who are Deaf or Hard of Hearing, A Critical Resource Needed for Legal Compliance and Code of Ethical Conduct for Teachers of Students who are Deaf or Hard of Hearing. The Code of Conduct includes a commitment to professional practice for all personnel who are involved with educating deaf and hard of hearing infants, children, and youth. These documents may be accessed at https://dcdcec.org/

Legislative Initiatives It is important to stay up to date with ongoing and evolving federal and state initiatives affecting students who are deaf or hard of hearing.

Language Equality and Acquisition for Deaf Kids Language Equality and Acquisition for Deaf Kids (LEAD-K) is an ongoing grassroots state-level initiative promoting kindergarten readiness literacy skills for children who are deaf or hard of hearing through American Sign Language (ASL) and English as described in the LEAD_K Fact Sheet (http://www.infantva.org/documents/LEAD-K-Website-At -A-Glance-FAQ.pdf). This movement was founded on the premise that all children who are deaf or hard of hearing will benefit from both languages. The basis for this assertion stems from research from the Visual Language and Visual Learning Center (VL2) at Gallaudet University (https://vl2 .gallaudet.edu/research/research-briefs) stating that the lack of early and fully accessible visual language exposure may contribute to poor reading levels in deaf children. Through

SUMMARY While many students have more opportunity because of the increased accountability, additional legislation, and other education initiatives of the past decade, there is still much work to do to ensure the required and recommended practices are implemented at the local school level in the intended manner. As practicing educational audiologists, we know that our time, finances, and administrative support have a significant impact on the services we can deliver. Another factor is the increased advocacy efforts of parents, made on behalf of their children. Some schools succumb to

Plural_Johnson_Ch01.indd 18

ongoing collaborations with other organizations, the initiative currently supports ASL, English (i.e., spoken English, written English, or English with or without the use of visual supplements), or both, and recognizes that parents have the right to choose the language methodology they use with their child. As each state group considers its constituents and current needs in early childhood deaf education services, collaborative efforts have resulted in several successful statutes that are designed to identify appropriate developmental assessments and track developmental milestones of children through age 5 and up to age 8. Successful legislation provides critical clarification in areas of IDEA that are overlooked when being applied to deaf and hard of hearing children. Furthermore, the legislation institutionalizes these policies rather than relying on the goodwill efforts of the people in charge at the state agency and local levels. Participation in local and state efforts such as this is important to ensure the values of all participant groups are represented.

Cogswell-Macy Various iterations of the Alice Cogswell and Anne Sullivan Macy Act have been introduced in Congress since 2013. The proposed act amends the Individuals with Disabilities Education Act to require a state to identify, evaluate, and provide special education and related services to children who have visual or hearing disabilities (or both) regardless of disability category. A state must also ensure that it has enough qualified personnel to serve children who have such disabilities and that a full continuum of alternative placements is available to meet the needs of disabled children for special education and related services. The primary bill authors have been the Conference of Educational Administrators of Schools and Programs for the Deaf (CEASD) and the American Federation of the Blind (AFB). Regardless of the status of this proposed legislation, it may be considered a way to introduce desired areas of modification when the next IDEA reauthorization is set.

vocal parents’ wishes rather than risk litigation, while other schools resist providing requested services leaving parents to engage in mediation or other legal recourse methods. The result often is that children of vocal parents get more services than those of quiet, compliant families even though children of the latter may be just as needy. States with strong leadership in deaf education have engaged in systemic reform efforts, most recently using the 2018 NASDSE Guidelines as an opportunity to consider gaps in services as well as strengths. We have learned that there are no simple answers to address the problems of underachievement. We have also learned that improve-

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ment requires state leaders and stakeholders to roll up their sleeves, work together to find common ground, and facilitate system change through creative planning and commitment to implementation. Although most educational audiologists have much to be proud of, as a profession, we are still wrestling with many of the same issues raised in the 1965 Joint Committee Report, “Audiology and Education of the Deaf” (Ventry, 1965), a project that was identified as a beginning to resolve the issues at the time. Read the following summary statements from that project and compare them with the list of challenges identified at the opening of this chapter. Expanding “deaf ” to “deaf and hard of hearing,” do you think we are there yet? 1. There is an undeniable need for increased emphasis to be placed on education of the deaf in audiology training programs. There is also a need, perhaps to a somewhat lesser extent, for increased emphasis on audiology in teacher of the deaf training programs. 2. There is a need for clarification of the roles and responsibilities of both audiologists and teachers of the deaf. 3. Interprofessional relationships need to be improved. One major method of accomplishing this is to increase contact and communication between the practicing teacher of the deaf and the clinical audiologist. 4. The audiologist needs greater exposure, probably by means of direct contact, to the educational and language problems imposed by deafness. Teachers need to be better able to utilize audiologic information in planning an educational program. 5. The audiologists can play an important and significant role in an educational program for deaf children. There needs, however, to be greater utilization of audiologic personnel in such programs. 6. If services are to be offered to deaf clients, they must be offered by individuals who are knowledgeable about problems related to deafness and who have had experiences with deaf people. 7. Audiologic research has much to contribute to deaf education, but there needs to be more cooperative research

Plural_Johnson_Ch01.indd 19

19

efforts, and these efforts need to be designed to solve, in part, some of the problems facing educators of the deaf. 8. Deaf education programs need to take greater advantage of the audiologic services available at speech and hearing centers. This is particularly true if the centers can offer a wide variety of services, especially diagnostic services. 9. The role of the speech pathologist in dealing with the speech and language problems associated with deafness needs to be reevaluated. 10. Greater understanding, appreciation, and respect for the contributions made by each professional group need to be fostered and enhanced. 11. The final conclusion is that maximum audiologic services are not currently being provided to, or utilized by, deaf children and adults. As a result, many deaf individuals fail to achieve their maximum potential (p. 116).

Chapter 1

Legislative and Policy Essentials

SUGGESTED READINGS AND RESOURCES National Association of State Directors of Special Education. (2018). Optimizing Outcomes for Students who are Deaf or Hard of Hearing: Educational Service Guidelines. Alexandria, VA: Author. Available from http://www.nasdse.org U.S. Department of Education, Office of Civil Rights (n.d.). Protecting Students With Disabilities: Frequently Asked Questions About Section 504 and the Education of Children with Disabilities. Available from https://www2.ed.gov/about/offices /list/ocr/504faq.html?exp=0 U.S. Department of Justice and U.S. Department of Education (2014, November 12). Frequently Asked Questions on Effective Communication for Students with Hearing, Vision, or Speech Disabilities in Public Elementary and Secondary Schools. Available from http://www2.ed.gov/about/offices/list/ocr/docs /dcl-faqs-effective-communication-201411.pdf

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APPENDIX

1–A

Comparison of Pertinent Areas of the Individuals With Disabilities Education Act (IDEA) Part B, Section 504, and the Americans With Disabilities Act (ADA) Chapter 1

Areas

IDEA

Section 504

ADA, Title II

Type

Education Act

Civil Rights Law

Civil Rights Law

Title

The Individuals with Disabilities Education Act (IDEA) (2004, amendments of 2008)

The Rehabilitation Act of 1973

Americans with Disability Act of 1990 (ADA) and ADA Amendments Act, 2008

Responsible Entity

Special education

General education

Public and private schools (religious schools are exempt)

Funding

State, local, and federal funding (IDEA funds cannot be used with students who are only eligible under 504)

No federal funding—state and local school responsibility

No federal funding—public and private responsibility

Adlinistrator

Special education director or designee

Section 504 coordinator (for entities with 15 employees or more)

504 Coordinator may oversee ADA responsibilities

Service Tool

Individualized Education Program (IEP)

■■

■■

Purpose

Population

To provide federal financial assistance to state and local education agencies to guarantee educational rights and benefits for children with disabilities including the right to a free appropriate public education, an IEP designed to meet the child’s unique needs, and procedural safeguards

Identifies 13 categories of qualifying conditions: ■■ Autism ■■ Deaf-blindness ■■ Deafness ■■ Emotional disturbance ■■ Hearing impairment ■■ Mental retardation ■■ Multiple disability ■■ Orthopedically impairment ■■ Other health impairment ■■ Specific learning disability ■■ Speech or language impairment ■■ Traumatic brain injury ■■ Visually impaired including blindness

■■

■■

■■

■■

■■

Appropriate academic adjustments Accommodations and/or services To protect the rights of individuals with disabilities from discrimination in programs and activities that receive federal financial assistance from the U.S. Department of Education To empower individuals with disabilities to maximize employment, economic selfsufficiency, independence, and inclusion and integration into society

Reasonable accommodations and legal employment practices

■■

To prohibit discrimination on the basis of disability by state and local governments in employment, public services, and accommodations

Identifies students as disabled so long as she/he meets the definition of qualified persons with disabilities (e.g., “has a physical or mental impairment; has a record of such impairment; or is regarded as having such an impairment”). An impairment that substantially limits a major life activity includes “caring for one’s self, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working” Determination must be made without considerations for “mitigating measures” Applies to all employers, schools and educational programs, nursing homes, mental health centers, and human service programs that receive or benefit from federal financial assistance

20

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21

Legislative and Policy Essentials

IDEA

Free Appropriate Public Education (FAPE)

Both require the provision of a free appropriate public education to eligible students, including individually designed instruction Requires the school to provide an IEP designed to meet the child’s unique needs and from which the child receives educational benefit (i.e., “appropriate education”)

Section 504

■■

■■

Eligibility

A student is only eligible to receive special education and/or related services if the multidisciplinary team determines that the student has a disability under one of the 13 qualifying conditions and requires specially designed instruction to receive FAPE

■■

■■

Requires the provision of regular or special education and related aids and services that are designed to meet individual educational needs as adequately as the needs of persons without disabilities are met developed in a 504 Plan “Appropriate” means an education comparable to the education provided to nondisabled students A student is eligible so long as she/he meets the definitions of qualified person with disabilities. The student is not required to need specially designed instruction in order to be protected Mitigating measures cannot be used to exclude students

ADA, Title II ■■

■■

■■

■■

■■

■■

Addresses education in terms of accessibility requirements but does not require individual entitlement for FAPE Works in conjunction with 504 Public entities cannot use employment practices that discriminate on the basis of a disability

Chapter 1

Areas

A person is eligible so long as she/he meets the definition of qualified person with disabilities Mitigating measures cannot be used to exclude a person ADAAA (2008) aligned ADA and 504 definitions of disabilities

Accessibility

Requires that accommodations and modifications must be made to provide access to a FAPE; IEP students automatically protected under 504 and ADA

Requires that public and private programs be accessible to individuals with disabilities and that “reasonable accommodations” are provided to students with disabilities

Undue Hardship

Size of the program and its budget, type of operation, nature, and cost of accommodation

Consideration is given for the size of the program, extent of accommodation, and cost relative to school budget

Size of the business and its budget, type of operation, nature, and cost of accommodation

Procedural Safeguards

Comprehensive system of safeguards including written notice prior to any change in placement and the right to an independent evaluation at public expense

Requires notice to parents regarding identification, evaluation, and/or placement. Written notice only required before a significant change in placement is made

No procedural safeguards related to special education; Makes provisions for public notice, hearings, complaint procedures, and consequences for noncompliance

Consent

Requires written consent before initial evaluation and placement

Does not require consent, but a school district would be wise to do so

Consent not required

Evaluation, Services, and Placement

Comprehensive evaluation, services, and placement according to IDEA regulations

Requires notice, not consent, for evaluation; evaluation procedures are same as IDEA; meeting not required for change of placement

No evaluation specified; only provision of reasonable accommodations and effective communication (Continues )

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22

Chapter 1

Areas

IDEA

Due Process

Both statutes require schools to provide impartial hearings for parents or guardians who disagree with the identification, evaluation, records who disagree with the identification, evaluation, records, or placement of students with disabilities Delineates specific requirements

Chapter 1

Enforcement

Enforced by the U.S. Office of Special Education Programs, U.S. Department of Education. Compliance is monitored by each state’s Department of Education, Office of Special Education Programs, with oversight by the U.S. Department of Education

Section 504

Requires that the parent have an opportunity to participate and be represented by counsel. Other details are left to the discretion of the school district. Policy statements should clarify specific details ■■

■■

Enforced by the U.S. Office for Civil Rights State Department of Education has no monitoring, complaint resolution, or funding involvement

ADA, Title II No specific due process procedures are delineated. Due process hearing can be initiated by either party. The court may allow the prevailing party, other than the United States, a reasonable attorney’s fee

In education, enforced by the U.S. Office for Civil Rights (each federal agency has its own 504 regulations that apply to its programs)

Note. Resources included https://www.ed.gov: 504, IDEA, Title II of ADA; Wrightslaw: IDEA 2004 (2006).

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APPENDIX

1–B

Part B, Education of Children With Disabilities (2004) (2006)

Part C, Early Intervention Program for Infants and Toddlers With Disabilities (2011)

Audiology

300.34(c)(1) AUDIOLOGY includes(i) Identification of children with hearing loss, (ii) Determination of the range, nature, and degree of hearing loss, including referral for medical or other professional attention for the habilitation of hearing; (iii) Provision of habilitation activities, such as language habilitation, auditory training, speech reading, (lipreading), hearing evaluation, and speech conservation; (iv) Creation and administration of programs for prevention of hearing loss; (v) Counseling and guidance of children, parents, and teachers regarding hearing loss; and (vi) Determination of the children’s need for group and individual amplification, selecting and fitting an appropriate aid, and evaluating the effectiveness of amplification.

303.13(b)(2) AUDIOLOGY SERVICES includes(i) Identification of children with auditory impairments, using at risk criteria and appropriate audiological screening techniques; (ii) Determination of the range, nature, and degree of hearing loss and communication functions, by use of audiologic evaluation procedures; (iii) Referral for medical and other services necessary for the habilitation or rehabilitation of an infant or toddler with a disability who has an auditory impairment; (iv) Provision of auditory training, aural rehabilitation, speech reading and listening devices, orientation and training, and other services; (v) Provision of services for the prevention of hearing loss; and (vi) Determination of the child’s need for individual amplification, including selecting, fitting, and dispensing of appropriate listening and vibrotactile devices, and evaluating the effectiveness of those devices.

Cochlear Implant Exception

300.34 RELATED SERVICES (b) Exception; services that apply to children with surgically implanted devices, including cochlear implants. (1) Related services do not include a medical device that is surgically implanted, the optimization of that device’s functioning (e.g., mapping), maintenance of that device, or the replacement of that device. (2) Nothing in paragraph (b)(1) of this section— (i) Limits the right of a child with a surgically implanted device (e.g., cochlear implant) to receive related services (as listed in paragraph (a) of this section) that are determined by the IEP Team to be necessary for the child to receive FAPE. (ii) Limits the responsibility of a public agency to appropriately monitor and maintain medical devices that are needed to maintain the health and safety of the child, including breathing, nutrition, or operation of other bodily functions, while the child is transported to and from school or is at school; or (iii) Prevents the routine checking of an external component of a surgically implanted device to make sure it is functioning properly, as required in §300.113(b).

303.16 HEALTH SERVICES (c) The term does not include-(1) Services that are-(iii) Related to the implementation, optimization (e.g., mapping), maintenance, or replacement of a medical device that is surgically implanted, including a cochlear implant. (A) Nothing in this part limits the right of an infant or toddler with a disability with a surgically implanted device (e.g. cochlear implant) to receive the early intervention services that are identified on the child’s IFSP as being needed to meet the child’s developmental outcomes. (B) Nothing in this part prevents the EIS provider from routinely checking that either the hearing aid or the external components of a surgically implanted device (e.g., cochlear implant) of an infant or toddler with a disability are functioning properly.

Chapter 1

Comparison of Pertinent Part B and Part C Individuals With Disabilities Education Act (IDEA) Requirements Related to Children and Youth Who Are Deaf or Hard of Hearing

(Continues )

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24

Chapter 1

Sign Language, SpeechLanguage, Pathology Services

Chapter 1

Part B, Education of Children With Disabilities (2004) (2006)

Part C, Early Intervention Program for Infants and Toddlers With Disabilities (2011)

300.34(c)(4) INTERPRETING SERVICES Interpreting services includes(i) The following when used with respect to children who are deaf or hard of hearing: oral transliteration services, cued language transliteration services, and sign language transliteration and interpreting services, and transcription services, such as communication access real-time translation (CART), C-Print, and TypeWell; and (ii) Special interpreting services for children who are deaf-blind.

303.13(b)(12) SIGN LANGUAGE AND CUED LANGUAGE SERVICES Sign language and cued language services include teaching sign language, cued language, and auditory/or language, providing oral transliteration services (such as amplification), and providing sign and cued language interpretation.

300.34(c)(15) SPEECH-LANGUAGE PATHOLOGY SERVICES - there is no reference to speech- language services specifically for children who are deaf or hearing impaired.

Assistive Technology

300.5 ASSISTIVE TECHNOLOGY DEVICE means any item, piece of equipment, or product system, whether acquired commercially, off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of a child with a disability. The term does not include a medical device that is surgically implanted, or the replacement of such device. 300.6 ASSISTIVE TECHNOLOGY SERVICE means any service that directly assists a child with a disability in the selection, acquisition, or use of an assistive technology device. The term includes(a) The evaluation of the needs of a child with a disability, including a functional evaluation of the child in the child’s customary environment; (b) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices by children with disabilities; (c) Selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices; (d) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs; (e) Training or technical assistance for a child with a disability or, if appropriate, that child’s family; and (f) Training or technical assistance for professionals (including individuals providing education or rehabilitation services), employers, or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of that child.

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303.13(b)(1) SPEECH-LANGUAGE PATHOLOGY SERVICES include-(i) Identification of children with communication or language disorders and delays in development of communication skills, including the diagnosis and appraisal of specific disorders and delays in those skills; (ii) Referral for medical or other professional services necessary for the habilitation or rehabilitation of children with communication or language disorders and delays in development of communication skills; and (iii) Provision of services for the habilitation, rehabilitation, or prevention of communication or language disorders and delays in development of communication skills. 303.13(b)(1)(i) ASSISTIVE TECHNOLOGY DEVICE means any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of an infant or toddler with a disability. The term does not include a medical device that is surgically implanted, including cochlear implants, or the optimization (e.g., mapping) or the maintenance or replacement of that device. 303.13(b)(1)(ii) ASSISTIVE TECHNOLOGY SERVICE means any service that directly assists an infant or toddler with a disability in the selection, acquisition, or use of an assistive technology device. The term includes-(A) The evaluation of the needs of an infant or toddler with a disability, including a functional evaluation of the infant or toddler with a disability in the child’s customary environment; (B) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices by infants or toddlers with disabilities; (C) Selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices; (D) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs; (E) Training or technical assistance for an infant or toddler with a disability or, if appropriate, that child’s family; and (F) Training or technical assistance for professionals (including individuals providing education or rehabilitation services) or other individuals who provide services to, or are otherwise substantially involved in the major life functions of, infants and toddlers with disabilities.

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Legislative and Policy Essentials

Part B, Education of Children With Disabilities (2004) (2006)

Part C, Early Intervention Program for Infants and Toddlers With Disabilities (2011)

Hearing Aid/ Cochlear Implant Function

300.113 ROUTINE CHECKING OF HEARING AIDS AND EXTERNAL COMPONENTS OF SURGICALLY IMPLANTED MEDICAL DEVICES (a) Hearing aids. Each public agency must ensure that hearing aids worn in school by children with hearing impairments, including deafness, are functioning properly. (b) External components of surgically implanted

medical devices.

(1) Subject to paragraph (b)(2) of this section, each public agency must ensure that the external components of surgically implanted medical devices are functioning properly. (2) For a child with a surgically implanted medical device who is receiving special education and related services under this part, a public agency is not responsible for the post-surgical maintenance, programming, or replacement of the medical device that has been surgically implanted (or of an external component of the surgically implanted medical device).

303.16(c) HEALTH SERVICES The term does not include-(1) Services that are-(iii) Related to the implementation, optimization (e.g., mapping), maintenance, or replacement of a medical device that is surgically implanted, including cochlear implants. (A) Nothing in this part limits the right of an infant or toddler with a disability with a surgically implanted device (e.g. cochlear implant) to receive the early intervention services that are identified on the child’s IFSP as being needed to meet the child’s developmental outcomes. (B) Nothing in this part prevents the EIS provider from routinely checking that either the hearing aid or the external components of a surgically implanted device (e.g., cochlear implant) of an infant or toddler with a disability are functioning properly.

Chapter 1

300.105(b) ASSISTIVE TECHNOLOGY On a case-by-case basis, the use of school-purchased assistive technology devices in a child’s home or in other settings is required if the child’s IEP Team determines that the child needs access to those devices in order to receive FAPE.

Consideration 300.324(2) DEVELOPMENT, REVIEW AND of Special REVISION OF IEP. Factors CONSIDERATION OF SPECIAL FACTORS. The IEP team must (iv) Consider the communication needs of the child and in the case of a child who is deaf or hard of hearing, consider the child’s language and communication needs, opportunities for direct communications with peers and professional personnel in the child’s language and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the child’s language and communication mode; and (v) Consider whether the child requires assistive technology devices and services. Native Language

300.29 NATIVE LANGUAGE(a) Native language, when used with respect to an individual who is limited English proficient, means the following: (1) The language normally used by that individual, or, in the case of a child, the language normally used by the parents of the child, except as provided in paragraph (a)(2) of this section.

303.25 NATIVE LANGUAGE(a) Native language, when used with respect to an individual who is limited English proficient or LEP (as that term is defined in section 602(18) of the Act), means: (1) The language normally used by that individual, or, in the case of a child, the language normally used by the parents of the child, except as provided in paragraph (a)(2) of this section; and (Continues )

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26

Chapter 1

Part C, Early Intervention Program for Infants and Toddlers With Disabilities (2011)

(2) In all direct contact with a child (including evaluation of the child), the language normally used by the child in the home or learning environment. (b) For an individual with deafness or blindness, or for an individual with no written language, the mode of communication that is normally used by the individual (such as sign language, Braille, or oral communication).

(2) For evaluations and assessments conducted pursuant to § 303.321(a)(5) and (a)(6), the language normally used by the child, if determined developmentally appropriate for the child by qualified personnel conducting the evaluation or assessment. (b) Native language, when used with respect to an individual who is deaf or hard of hearing, blind or visually impaired, or for an individual with no written language, means the mode of communication that is normally used by the individual (such as sign language, braille, or oral communication).

Disability Definitions

300.8(b) DEFINITIONS [2] Deaf-blindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness. [3] Deafness means a hearing impairment that is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification that adversely affects a child’s educational performance. [5] Hearing impairment means an impairment in hearing, whether permanent or fluctuating, that adversely affects a child’s educational performance but that is not included under the definition of deafness in this section

303.21 INFANT OR TODDLER WITH A DISABILITY (a) Infant or toddler with a disability means an individual under three years of age who needs early intervention services because the individual(1) is experiencing a developmental delay, as measured by appropriate diagnostic instruments and procedures, in one or more of the following areas: (i) Cognitive development. (ii) Physical development, including vision and hearing. (iii) Communication development. (iv) Social or emotional development. (v) Adaptive development; or (2) Has a diagnosed physical or mental condition that – (i) Has a high probability of resulting in developmental delay; and (ii) Includes conditions such as chromosomal abnormalities; genetic or congenital disorders; sensory impairments; inborn errors of metabolism; disorders reflecting disturbance of the development of the nervous system; congenital infections; severe attachment disorders; and disorders secondary to exposure to toxic substances, including fetal alcohol syndrome.

Program

300.22 INDIVIDUALIZED EDUCATION PROGRAM or IEP means a written statement for a child with a disability that is developed, reviewed, and revised in accordance with 300.320 through 300.324

303.20 INDIVIDUALIZED FAMILY SERVICE PLAN or IFSP means a written plan for providing early intervention services to an infant or toddler with a disability under this part and the infant’s or toddler’s family that-(a) Is based on the evaluation and assessment described in Sec. 303.320; (b) Includes the content specified in Sec. 303.344; (c) Is implemented as soon as possible once parental consent to early intervention services on the IFSP is obtained (consistent with Sec. 303.420); and (d) Is developed in accordance with the IFSP procedures in Sec. Sec. 303.342, 303.343, and 303.345.

Chapter 1

Part B, Education of Children With Disabilities (2004) (2006)

300.101 FAPE: CHILDREN ADVANCING FROM GRADE TO GRADE (c) (1) Each state must assure that FAPE is available to any individual child with a disability who needs special education and related services, even though the child has not failed or been retained in a course or grade and is advancing from grade to grade.

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Educational Environment

Service Provider/ Qualified Personnel

Part B, Education of Children With Disabilities (2004) (2006)

Part C, Early Intervention Program for Infants and Toddlers With Disabilities (2011)

300.114(a) LEAST RESTRICTIVE ENVIRONMENT. (2) Each public agency must ensure that (i) To the maximum extent appropriate, children with disabilities, including children in public or private institutions or other care facilities, are educated with children who are nondisabled; and (ii) Special classes, separate schooling, or other removal of children with disabilities from the regular educational environment occurs only if the nature or severity of the disability is such that education in regular classes with the use of supplementary aids and services cannot be achieved satisfactorily.

303.26 NATURAL ENVIRONMENTS. Natural environments means settings that are natural or typical for a same-aged infant or toddler without a disability, may include the home or community settings, and must be consistent with the provisions of Sec. 303.126.

[NOTE: There are no specific qualifications for teachers or related services providers serving students with disabilities who have hearing impairments.] The following regulations apply to all personnel.

303.12 Early intervention service provider. (a) Early intervention service provider or EIS provider means an entity (whether public, private, or nonprofit) or an individual that provides early intervention services under part C of the Act, whether or not the entity or individual receives Federal funds under part C of the Act, and may include, where appropriate, the lead agency and a public agency responsible for providing early intervention services to infants and toddlers with disabilities in the State under part C of the Act. (b) An EIS provider is responsible for— (1) Participating in the multidisciplinary individualized family service plan (IFSP) Team’s ongoing assessment of an infant or toddler with a disability and a family-directed assessment of the resources, priorities, and concerns of the infant’s or toddler’s family, as related to the needs of the infant or toddler, in the development of integrated goals and outcomes for the IFSP; (2) Providing early intervention services in accordance with the IFSP of the infant or toddler with a disability; and (3) Consulting with and training parents and others regarding the provision of the early intervention services described in the IFSP of the infant or toddler with a disability. (Continues )

300.156 PERSONNEL QUALIFICATIONS (a) General. The SEA must establish and maintain qualifications to ensure that personnel necessary to carry out the purposes of this part are appropriately and adequately prepared and trained, including that those personnel have the content knowledge and skills to serve children with disabilities. (b) Related services personnel and paraprofessionals. The qualifications under paragraph (a) of this section must include qualifications for related services personnel and paraprofessionals that -(1) are consistent with any State-approved or State-recognized certification, licensing, registration, or other comparable requirements that apply to the professional discipline in which those personnel are providing special education or related services; and

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303.126 EARLY INTERVENTION SERVICES IN NATURAL ENVIRONMENTS. Each system must include policies and procedures to ensure, consistent with Sec. Sec. 303.13(a)(8) (early intervention services), 303.26 (natural environments), and 303.344(d)(1)(ii) (content of an IFSP), that early intervention services for infants and toddlers with disabilities are provided-(a) To the maximum extent appropriate, in natural environments; and (b) In settings other than the natural environment that are most appropriate, as determined by the parent and the IFSP team, only when early intervention services cannot be provided satisfactorily in a natural environment.

Chapter 1

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Chapter 1

Part B, Education of Children With Disabilities (2004) (2006)

Chapter 1 Specially Designed Instruction

Part C, Early Intervention Program for Infants and Toddlers With Disabilities (2011)

(2) Ensure that related services personnel who deliver services in their discipline or profession-(i) Meet the requirements of paragraph (b)(1) of this section; and (ii) Have not had certification or licensure requirements waived on an emergency, temporary, or provisional basis; and (iii) Allow paraprofessionals and assistants who are appropriately trained and supervised, in accordance with State law, regulation, or written policy, in meeting the requirements of this part to be used to assist in the provision of special education and related services under this part to children with disabilities.

303.13(c) QUALIFIED PERSONNEL. The following are the types of qualified personnel who provide early intervention services under this part: (1) Audiologists. (2) Family therapists. (3) Nurses. (4) Occupational therapists. (5) Orientation and mobility specialists. (6) Pediatricians and other physicians for diagnostic and evaluation purposes. (7) Physical therapists. (8) Psychologists. (9) Registered dieticians. (10) Social workers. (11) Special educators, including teachers of children with hearing impairments (including deafness) and teachers of children with visual impairments (including blindness). (12) Speech and language pathologists. (13) Vision specialists, including ophthalmologists and optometrists.

300.39 Special education (a) General. (1) Special education means specially designed instruction, at no cost to the parents, to meet the unique needs of a child with a disability, including— (i) Instruction conducted in the classroom, in the home, in hospitals and institutions, and in other settings; and (ii) Instruction in physical education. (3) Specially designed instruction means adapting, as appropriate to the needs of an eligible child under this part, the content, methodology, or delivery of instruction— (i) To address the unique needs of the child that result from the child’s disability; and (ii) To ensure access of the child to the general curriculum, so that the child can meet the educational standards within the jurisdiction of the public agency that apply to all children.

303.13 (b)(14) Special instruction Special instruction includes(i) The design of learning environments and activities that promote the infant’s or toddler’s acquisition of skills in a variety of developmental areas, including cognitive processes and social interaction; (ii) Curriculum planning, including the planned interaction of personnel, materials, and time and space, that leads to achieving the outcomes in the IFSP for the infant or toddler with a disability; (iii) Providing families with information, skills, and support related to enhancing the skill development of the child; and (iv) Working with the infant or toddler with a disability to enhance the child’s development.

Note. Prepared by Cheryl DeConde Johnson, https://ADEvantage.com (May 22, 2019).

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APPENDIX

1–C Summary of Laws Pertaining to Persons Who Are Deaf or Hard of Hearing

Individuals With Disabilities Education Act (IDEA) (amended 2004) http://idea.ed.gov

Main Themes ■■ ■■ ■■

Free and appropriate public education (FAPE) Education in the least restrictive environment (LRE) Individualized Education Program (IEP)

Regulatory Authority The Office of Special Education Programs, Office of Special Education and Rehabilitative Services, U.S. Department of Education

Chapter 1

Law or Regulation

Every Student Succeeds Act (ESSA) (amended 2015); https://www.ed.gov/essa

The ESSA replaced NCLB as the reauthorized Elementary and Secondary Education Act (ESEA), the federal law guiding public education from kindergarten through high school. ESSA continues the focus on accountability for all students but increases state control and flexibility to close achievement gaps, increase equity, improve the quality of instruction, and increase outcomes for all students.

U.S. Department of Education

504 (Section 504 of the Rehabilitation Act of 1973) http://www.ed.gov/about/offices/list /ocr/docs/edlite-FAPE504.html Subpart A: General Provisions Subpart B: Employment Practices Subpart C: Program Accessibility Subpart D: Preschool, Elementary and Secondary Education Subpart E: Post-Secondary Setting Subpart F: Health, Welfare, and Social Services Subpart G: Procedures

School-age: FAPE Other populations: all employers, schools and educational programs, nursing homes, mental health centers, and human service programs that receive or benefit from federal financial assistance. Under Section 504, any qualified individual with a disability1 has the right to a reasonable accommodation, such as services or aids, to help that individual participate in the programs or jobs offered by the federally funded employer, school, or other organization Postsecondary: ■■ Appropriate academic adjustments as necessary to ensure that it does not discriminate based on disability. If a postsecondary school provides housing to nondisabled students, it must provide comparable, convenient, and accessible housing to students with disabilities at the same cost. ■■ The program does not have to make modifications that would fundamentally alter the nature of a service, program, or activity or would result in undue financial or administrative burdens.

Office for Civil Rights (OCR), U.S. Department of Education

508 (Section 508 of the Rehabilitation Act of 1973, amended 1998) https://www .section508.gov/manage/laws -and-policies

Requires federal departments and agencies that develop, procure, maintain, or use electronic and information technology to ensure that federal employees and members of the public with disabilities have access to and use of information and data comparable to those of the employees and members of the public without disabilities unless it is an undue burden to do so. The U.S. Access Board, responsible for developing standards for Information and Communication Technology (ICT), issued final standards and guidelines effective January 18, 2018.

Office for Civil Rights (OCR), U.S. Department of Justice

(Continues )

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Chapter 1

Chapter 1

Law or Regulation

Main Themes

Regulatory Authority

Americans With Disabilities Act (ADA) of 1990 amended 2008 ■■ Title II: all services, programs, and activities, including provided to the public by state and local governments, including stateoperated schools, colleges, and universities https://www .ada.gov/regs2010/titleII_2010 /titleII_2010_regulations.htm ■■ Title III: places of public accommodation (businesses and nonprofit agencies that serve the public) and “commercial facilities” (other businesses), including private schools, colleges, and universities

Prohibits discrimination on the basis of disability including standards for effective communication in employment, public services, and accommodations; sections include (responsible agency in parenthesis): ■■ /TBL/Employment (Equal Employment Opportunity Center) ■■ Public Transportation (U.S. Department of Transportation) ■■ Telephone Relay Service (Federal Communications Commission) ■■ Design Guidelines (U.S. Access Board) ■■ Education (U.S. Department of Education) ■■ Health Care (U.S. Department of Health and Human Services) ■■ Labor (U.S. Department of Labor) ■■ Housing (U.S. Department of Housing and Urban Development) ■■ Parks and Recreation (U.S. Department of the Interior) ■■ Agriculture (U.S. Department of Agriculture)

Education: Office for Civil Rights (OCR), U.S. Department of Education All other areas: U.S. Department of Justice, Civil Rights Division, Disability Rights Section

Family Educational Rights and Privacy Act (FERPA) (1974, regulations amended 2011) http://www.ed.gov/policy/gen/guid /fpco/ferpa/index.html

■■

■■

Health Insurance Portability and Accountability Act (HIPAA) (1996) http://www.hhs.gov/ocr/privacy /index.html http://www.hhs.gov/ocr/privacy /hipaa/understanding/consumers /index.html

■■

■■

■■

■■

Occupational Safety and Health Administration (OSHA) http://www.osha.gov/ 1

The FERPA (20 U.S.C. § 1232g; 34 CFR Part 99) is a federal law that protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives parents certain rights with respect to their children’s education records. These rights transfer to the student when he or she reaches the age of 18 years or attends a school beyond the high school level. Students to whom the rights have transferred are “eligible students.”

U.S. Department of Education Complaints: Office for Civil Rights, U.S. Department of Education

Improved efficiency in health care delivery by standardizing electronic data interchange Protection of confidentiality and security of health data through setting and enforcing standards Exclusion of schools: In most cases, the HIPAA Privacy Rule does not apply to an elementary or secondary school because the school either: (1) is not a HIPAA covered entity or (2) is a HIPAA covered entity but maintains health information only on students in records that are by definition “education records” under FERPA and, therefore, is not subject to the HIPAA Privacy Rule. (https://www.hhs.gov/hipaa /for-professionals/faq/513/does-hipaa-apply-to-an -elementary-school/index.html)  Contains confidentiality exceptions

U.S. Department of Health and Human Services Complaints: Office for Civil Rights, U.S. Department of Health and Human Services

Requires monitoring of noise levels, noise exposure, and use of ear protection in work environments

U.S. Department of Labor

The categories of disability were expanded to align with ADA 2008.

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Appendix 1–D IDEA 2004 Key Regulations Pertaining to Audiology and Deaf Education PART B RELATED SERVICES 34CFR300.34(b)

Exception; services that apply to children with surgically implanted devices, including cochlear implants. (1) Related services do not include a medical device that is surgically implanted, the optimization of that device’s functioning (e.g., mapping), maintenance of that device, or the replacement of that device. (2) Nothing in paragraph (b)(1) of this section— (i) Limits the right of a child with a surgically implanted device (e.g., cochlear implant) to receive related services (as listed in paragraph (a) of this section) that are determined by the IEP Team to be necessary for the child to receive FAPE. (ii) Limits the responsibility of a public agency to appropriately monitor and maintain medical devices that are needed to maintain the health and safety of the child, including breathing, nutrition, or operation of other bodily functions, while the child is transported to and from school or is at school; or (iii) Prevents the routine checking of an external component of a surgically-implanted device to make sure it is functioning properly, as required in §300.113(b).

PART C DEFINITION OF AUDIOLOGY 34CFR303.13(b)(2) (2011)

Audiology services includes(i) Identification of children with auditory impairments, using at risk criteria and appropriate audiological screening techniques; (ii) Determination of the range, nature, and degree of hearing loss and communication functions, by use of audiologic evaluation procedures; (iii) Referral for medical and other services necessary for the habilitation or rehabilitation of an infant or toddler with a disability who has an auditory impairment; (iv) Provision of auditory training, aural rehabilitation, speech reading and listening devices, orientation and training, and other services; (v) Provision of services for the prevention of hearing loss; and (vi) Determination of the child's need for individual amplification, including selecting, fitting, and dispensing of appropriate listening and vibrotactile devices, and evaluating the effectiveness of those devices.

PART B - DEFINITION OF AUDIOLOGY 34CFR300.34(c)(1)

Audiology includes(i) Identification of children with hearing loss; (ii) Determination of the range, nature, and degree of hearing loss, including referral for medical or other professional attention for the habilitation of hearing; (iii) Provision of habilitation activities, such as language habilitation, auditory training, speech reading, (lipreading), hearing evaluation, and speech conservation; (iv) Creation and administration of programs for prevention of hearing loss; (v) Counseling and guidance of children, parents, and teachers regarding hearing loss; and (vi) Determination of children’s needs for group and individual amplification, selecting and fitting an appropriate aid, and evaluating the effectiveness of amplification.

PART B INTERPRETING SERVICES 34CFR300.34(c)(4)

Interpreting services includes(i) The following when used with respect to children who are deaf or hard of hearing: oral transliteration services, cued language transliteration services, and sign language transliteration and interpreting services, and transcription services, such as communication access real-time translation (CART), C-Print, and TypeWell; and (ii) Special interpreting services for children who are deaf-blind.

ASSISTIVE TECHNOLOGY 300.105(a)(2)

On a case-by-case basis, the use of school-purchased assistive technology devices in a child’s home or in other settings is required if the child’s IEP Team determines that the child needs access to those devices in order to receive FAPE.

Compiled by Cheryl DeConde Johnson, Ed.D., The ADEvantage. (2011)

PART B ROUTINE CHECKING OF HEARING AIDS AND EXTERNAL COMPONENTS OF SURGICALLY IMPLANTED MEDICAL DEVICES 34CFR300.113

(a) Hearing aids. Each public agency must ensure that hearing aids worn in school by children with hearing impairments, including deafness, are functioning properly. (b) External components of surgically implanted medical devices. (1) Subject to paragraph (b)(2) of this section, each public agency must ensure that the external components of surgically implanted medical devices are functioning properly. (2) For a child with a surgically implanted medical device who is receiving special education and related services under this part, a public agency is not responsible for the post-surgical maintenance, programming, or replacement of the medical device that has been surgically implanted (or of an external component of the surgically implanted medical device).

PART B DEVELOPMENT, REVIEW, AND REVISION OF IEP, Consideration of special factors 34CFR300.324(2)(iv)

The IEP Team must(iv) Consider the communication needs of the child, and in the case of a child who is deaf or hard of hearing, consider the child’s language and communication needs, opportunities for direct communications with peers and professional personnel in the child’s language and communication mode, academic level, and full range of needs, including opportunities for direct instruction in the child’s language and communication mode; (v) Consider whether the child needs assistive technology devices and services.

ASSISTIVE TECHNOLOGY PART B 34CFR300.5-.6 & PART C 34CFR303.13(b)(1)(i)

Assistive technology device means any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of children with disabilities. The term does not include a medical device that is surgically implanted, or the replacement of such device. Assistive technology service means any service that directly assists a child with a disability in the selection, acquisition, or use of an assistive technology device. The term includes(a) The evaluation of the needs of a child with a disability, including a functional evaluation of the child in the child’s customary environment; (b) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices by children with disabilities; (c) Selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices; (d) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs; (e) Training or technical assistance for a child with a disability or, if appropriate, that child’s family; and (f) Training or technical assistance for professionals (including individuals providing education or rehabilitation services), employers, or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of children with disabilities.

PART B DEFINITIONS 34CFR300.8(c)

[2] Deaf-blindness means concomitant hearing and visual impairments, the combination of which causes such severe communication and other developmental and educational needs that they cannot be accommodated in special education programs solely for children with deafness or children with blindness. [3] Deafness means a hearing impairment that is so severe that the child is impaired in processing linguistic information through hearing, with or without amplification that adversely affects a child’s educational performance. [5] Hearing impairment means an impairment in hearing, whether permanent or fluctuating, that adversely affects a child’s educational performance but that is not included under the definition of deafness in this section.

Copyright © 2021 Plural Publishing, Inc. All rights reserved. Permission to print for clinical use is granted. The files are NOT allowed to be hosted electronically without written permission of the publisher.

CHAPTER

2

Roles and Responsibilities of Educational Audiologists

Chapter 2

CONTENTS Roles of Educational Audiologists Educational Audiologists as Service Coordinators ■ Educational Audiologists as Instructional Team Members ■ Educational Audiologists as Consultants Educational Audiologists in Schools for the Deaf Responsibilities of Educational Audiologists Identification ■ Assessment ■ Habilitation ■ Hearing Loss Prevention ■ Counseling and Coaching ■ Amplification, Cochlear Implants, and Other Assistive Technology Ethical Considerations Educational Audiology Service Delivery Models School-Based Audiology Services ■ Contracted Audiology Services ■ Combined School-Based and Contractual Agreement ■ Telepractice

“I’m going with my teacher to see my educational audiologist.”

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CONTENTS 

(Continued )

Chapter 2

Establishing and Expanding Educational Audiology Services in the Schools Reimbursement for Educational Audiology Services ■ Dispensing Personal Hearing Instruments ■ Cerumen Management ■ Support for Early Hearing Detection and Intervention Training for Educational Audiologists Summary Suggested Readings and Resources Appendices 2–A Educational Audiology Association: Supporting Students who are Deaf and Hard of Hearing: Shared and Suggested Roles of Educational Audiologists, Teachers of the Deaf and Hard of Hearing, and SpeechLanguage Pathologists, Checklist (Text/Online) 2–B Part C Roles of Audiologists in Early Hearing Detection and Intervention (Text/Online) 2–C Educational Audiology Association: Educational Audiology Scope of Practice (Text/Online)

KEY TERMS Educational audiologist, school-based audiologist, educationally significant hearing loss, specialized instructional support personnel (SISP), telepractice/teleaudiology, workload approach

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The roles of educational audiologists vary depending on other services and personnel available to assist children within the school system. Educational audiology responsibilities are described in legislation (e.g., Individuals with Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act of 1973) and delineated in professional scopes of practice. Results from case law may provide additional interpretation of these responsibilities. Educational audiologists are critical members of educational teams that develop and implement programs and support for individual students who are deaf or hard of hearing and may serve as service coordinator, instructional team member, and/or consultant. Educational audiologists provide identification and intervention services as well as accommodations for students with hearing and listening challenges in general and special education settings. Factors impacting delivery models for educational audiology services include number and type of schools and student populations, geographic territory to be covered, specific needs of identified deaf or hard of hearing students, and availability and expertise of other specialized instructional and support personnel.

School-based audiologists are in a unique position to facilitate and support the education of students with reduced hearing. Unfortunately, the need to have comprehensive audiology services within school systems is often not obvious to administrators, teachers, and parents. These individuals may be aware of legal mandates to provide equal access and appropriate services for deaf and hard of hearing students, but they may seek to do so using a more traditional clinical model of audiology services. The clinical model focuses on diagnosis of hearing levels, and intervention often is limited to medical management and/or the provision of personal amplification. The importance of these services should not be diminished, but the educational impact of reduced hearing must be comprehensively assessed and interventions implemented to appropriately and fully meet the individual needs of each student. To create an educational audiology position in a school district or to expand existing services for deaf and hard of hearing students, it is imperative that educational audiologists understand their role and responsibilities in the educational system. Educational audiologists must work with their school administration to define their positions and to develop a plan for delivering audiology services to all students including those with hearing and listening challenges and those with normal hearing levels. After audiology services are in place in a school system, educational audiologists should continue to advocate for their services by providing evidence that illustrates their impact. Without continued awareness of the importance of educational audiology services, these services may not be used effectively and may eventually be reduced or eliminated. Additionally, documenting outcomes of services provides accountability, a critical component for sustainability of any program.

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This chapter addresses the following questions: ■■ ■■

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What are the roles of educational audiologists? What responsibilities do educational audiologists have in learning environments? What knowledge and skills are necessary for the practice of educational audiology? What systems can be implemented for effective and efficient delivery of educational audiology services? What strategies can be used to expand and improve the effectiveness of audiology services in the schools?

ROLES OF EDUCATIONAL AUDIOLOGISTS The roles of educational audiologists vary depending on the services and other specialized instructional and support personnel that are available to assist children within the school system. Educational audiologists are members of the educational team and, in addition to performing traditional audiology activities described in audiology scope of practice documents and state licensure laws, may serve at various times in any or all of the following capacities: ■■ ■■ ■■

service coordinator; instructional team member; and/or consultant.

gist may also be designated by the educational team as the service coordinator for a student with reduced hearing who is receiving multiple special education services. In either of these situations, the educational audiologist provides results, interpretations, and recommendations resulting from routine diagnostic audiology services and functional listening evaluations. In addition, educational audiologists work with the general and special education teachers, the student, the parents, and other relevant school professionals to see that appropriate services and classroom accommodations are provided. As the service coordinator, the educational audiologist is responsible for monitoring the student’s educational progress and plays a key role in facilitating changes in educational placement and/or accommodations when changes are necessary. Service coordinator responsibilities for educational audiologists may include the following: ■■

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Educational Audiologists as Service Coordinators When students with reduced hearing are not receiving direct special education services, such as students in general education with Section 504 plans, the educational audiologist often functions as their service coordinator with responsibilities for monitoring their educational performance and managing their accommodations. The educational audiolo-

Educational Audiologists deliver a full spectrum of hearing services to all children, particularly those in educational settings. Audiologists are trained to diagnose, manage, and treat hearing and balance problems. Educational audiologists are members of the school multidisciplinary team who facilitate listening, learning, and communication access via specialized assessments; monitor personal hearing instruments; recommend, fit, and manage hearing assistance technology; provide and recommend support services and resources; and advocate on behalf

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preparing teachers and other service providers to support students with a variety of hearing levels and communication needs; ensuring that all identified individual student services (e.g., speech-language pathology, interpreting, counseling) are provided in a collaborative and timely fashion; providing regular support to teachers and other school staff; monitoring student progress and outcomes; monitoring student placements and making recommendations for review and further assessment when needed; supporting transitions between learning environments, grades, schools, and postsecondary education, training, and employment; and maintaining complete and accurate information regarding potential placement options within the local education agency (LEA), as well as those in the applicable region and state.

Chapter 2

Roles and Responsibilities of Educational Audiologists

A more detailed discussion on the implementation of these responsibilities is provided in Chapter 9, Case Management and Habilitation.

of the students. Educational audiologists provide evidence for needed services and technology, emphasize access skills and supports, counsel children to promote personal responsibility and self-advocacy, maintain student performance levels, collaborate with private-sector audiologists, help student transitions, and team with other school professions to work most effectively to facilitate student learning. [edaud.org (n.d.)]

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Chapter 2

Educational Audiologists as Instructional Team Members

Chapter 2

There are many circumstances in which an educational audiologist functions as a member of the instructional team, providing support to teachers and other staff. When a student receives special education services, whether it is a program for deaf and hard of hearing children or for students with other learning challenges, the audiologist typically collaborates with and provides support to the special education teacher, the general education teacher, other specialized instructional personnel, the student, and the parents. This support is focused most often on assessing the hearing status, understanding and communicating the implications of the hearing status, and managing amplification and the student’s learning environment to ensure communication accessibility. Support may also include direct habilitation, facilitating development of self-advocacy skills, or other services. When teachers are not familiar with decreased hearing and its implications, the support provided by the educational audiologist typically is expanded to include in-service, coaching, and consultation with other members of the educational team. A comprehensive discussion of the educational audiologist’s activities as a member of the instructional team is provided in Chapter 9, Case Management and Habilitation; Chapter 10, Supporting Wellness and Social-Emotional Competence; and Chapter 14, Educational Considerations for Students Who Are Deaf or Hard of Hearing.

Educational Audiologists as Consultants Educational audiologists provide consultation to all teachers, including those who may not have children with identified hearing challenges in their classrooms. Teacher requests may include, but are not limited to, any of the following: ■■

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information about a specific child’s hearing sensitivity or auditory processing ability; activities for improving their students’ listening skills; information about how to integrate and reinforce specific auditory skills into classroom instruction (see Universal Design for Learning in Chapter 7); classroom presentations related to the function of the ear, hearing disorders, hearing loss prevention, or deaf culture; information about classroom acoustics; assistance with the use of classroom audio distribution systems (CADS) (aka classroom amplification systems) or other remote microphone listening technologies; or suggestions for classroom accommodations for instruction and standardized testing.

EDUCATIONAL AUDIOLOGISTS IN SCHOOLS FOR THE DEAF Educational audiologists who work at schools for the deaf serve in the capacities described earlier, but they often have

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slightly different roles and responsibilities. For example, because they function in a school setting that serves an already identified population of students, their role in screening and identification may be primarily one of community support and collaboration with other schools or public health programs (e.g., infant and early childhood hearing detection and intervention [EHDI]). In addition, schools for the deaf are typically structured around a Deaf culture environment, requiring knowledge of American Sign Language and sensitivity to communication, terminology, and identity issues that may not be as pervasive in general education school programs. Educational audiologists are uniquely qualified to guide educational teams and families in pursuing language and learning proficiency through one or both languages used in these specialized learning environments. Although still having a goal of maximizing audition, listening, and access for deaf and hard of hearing children and youth who are able and desire to incorporate audition into their communication, educational audiologists working in schools for the deaf may have to be creative in designing environments in which students are able to use and practice these skills. The number of students who use cochlear implants is continuing to increase at schools for the deaf, resulting in a greater potential to use listening and spoken language (LSL), cued speech, and other spoken language strategies in these environments. As reported by Nussbaum et al. (2017), these students are ethnically, culturally, and educationally diverse, but they have a bond stemming from their experiences with implanted devices. The educational audiologist is a critical resource for students in making connections with others using implanted devices, as well as supporting students in the care and use of their implants and related assistive devices. Educational audiologists are critical team partners with other school personnel in the development and implementation of communication strategies and accommodations both within and outside of the formal classroom setting. In residential and day schools for the deaf, there may be increased opportunities for audiologists to provide habilitation, support, and collaboration in addition to the responsibilities of educational audiologists described later in this chapter and listed in Table 2–1. Communication labs and other similar programs provide children and youth with

Nuggets from the Field Educational audiologists working within schools for the deaf should possess a strong sense of language equality and be proficient in both American Sign Language and spoken English.

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a very functional approach to communication development, and these programs often combine listening skill development, speechreading/visual communication skills, selfadvocacy development, remote microphone hearing assistance technology (RM HAT), and other assistive systems and technology to help students maximize their communication skills and academic outcomes. Many schools for the deaf are experiencing increased enrollment of students with additional learning challenges. Educational audiologists in this work environment must possess knowledge of a wide variety of disability categories and be able to guide the educational team in determining which strengths and needs are hearing related rather than a function of other cognitive, physical, or emotional needs. These audiologists may be able to guide the dispensing audiologist in choosing personal amplification with features that are functional for the student and the student’s family. Finally, schools for the deaf often provide outreach support and expertise to area public school programs serving a variety of students who are deaf or hard of hearing. Educational audiologists in this role provide expertise in Individualized Education Program (IEP) goal development, accommodations, and supports needed for successful mainstream experiences.

RESPONSIBILITIES OF EDUCATIONAL  AUDIOLOGISTS Regardless of the roles assumed by educational audiologists, there are many responsibilities they must address. Responsibilities outlined in the Individuals with Disabilities Education Act (IDEA) (2004)1 include the categories of identification, assessment, habilitation, prevention, counseling, and amplification. Assistive technology and assistive technology services and proper functioning of hearing aids are additional areas defined separately in IDEA2 (see Chapter 1, Appendix 1–B). A more detailed list of suggested responsibilities for audiologists who are employed in the schools is provided in Table 2–­1. Responsibilities of educational audiologists are discussed in this chapter according to the following areas: ■■ ■■ ■■ ■■ ■■ ■■

identification; assessment; habilitation; hearing loss prevention; counseling and guidance; and amplification, cochlear implants, and other assistive technology.

35

At times, the responsibilities of educational audiologists may overlap with those of other school personnel, particularly speech-language pathologists, counselors, and teachers of deaf and hard of hearing students. When this occurs, it is important to delineate which individual has primary responsibility for each student need so that all areas are covered. The Educational Audiology Association (EAA) has published a comprehensive and collaborative approach to addressing the needs of deaf and hard of hearing students, Supporting students who are deaf and hard of hearing: Shared and suggested roles of educational audiologists, teachers of the deaf and hard of hearing, and speech-language pathologists, presented in Appendix 2–A. Individual school district or agency personnel may alter the responsibility for each activity unless prohibited by state licensure or professional scope of practice. The checklist in Appendix 2–A contains the following areas: (a) audiological and equipment needs; (b) speech, language, auditory, and visual needs; (c) communication—speech, language, auditory, and visual needs; (d) academic needs; and (e) collaboration program management needs for students who are deaf or hard of hearing. Each area should be discussed and student needs identified. Individual responsibility should be designated based on specific student needs to ensure that all relevant components of the checklist are assigned to a team member for follow-up. Periodic meetings should be held to discuss new students and review existing student checklists to ensure all are receiving the services they need. Other specialized instructional support personnel (e.g., speech-language pathologists, educational interpreters, school psychologists, counselors, social workers) who are part of the student’s educational team should be included as individual systems require.

Chapter 2

Roles and Responsibilities of Educational Audiologists

Identification Identification of hearing status is one responsibility that is almost always a part of the educational audiologist’s role. Although educational audiologists generally do not perform population-based hearing screening services, they may be responsible for the administration and supervision of a school hearing screening program. They may also collaborate with community-based audiologists and other agencies to facilitate the identification of infants, toddlers, and preschoolers with reduced hearing and those who are at risk for later-onset hearing changes. A full discussion of hearing identification programs is provided in Chapter 4, Hearing Screening and Identification. Chapter 15, Collaborative School–Community Partnerships, includes more infor­ mation about how community systems can work together to ensure that children who are deaf or hard of hearing are identified.

1

34CFR300.34[c]1; 34CFR303.12[d]. 34CFR300.5-.6; 34CFR303.12; 34CFR300.15[b].

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Chapter 2

TABLE 2–1  Suggested Responsibilities of Audiologists Employed in the Schools Identification of hearing loss ■■ Collaborate with state and local early hearing detection and intervention (EHDI) programs and other community resources to promote awareness and implications of hearing and listening challenges, access to screening services, and awareness of and access to programs and services to support deaf/hard of hearing children and their families. ■■ Collaborate in the establishment, administration, and implementation of programs to identify hearing and listening challenges for children between birth and 21 years of age. ■■ Utilize screening tools that have been validated, reflect best practices, and are culturally and developmentally appropriate. ■■ Facilitate efficient transition from initial screening through diagnosis and intervention within the educational system. ■■ Assist in training and support for individuals that implement childhood hearing screening programs. ■■ Document effectiveness of screening programs through appropriate outcome measures.

Chapter 2

Assessment ■■ Administer and interpret behavioral and electrophysiologic measures of the peripheral and central auditory systems using calibrated equipment in appropriate acoustical environments. ■■ Provide comprehensive audiological assessments using appropriate protocols and materials that are standardized, developmentally appropriate, free from cultural bias, and in compliance with local, state, and federal education requirements. ■■ Administer and interpret results of functional listening assessments. ■■ Assist in the identification and management of students with auditory processing disorders. ■■ Provide written and verbal interpretation of audiological assessment results, functional implications, and management recommendations. ■■ Make appropriate referrals for further audiological, communication, educational, psychosocial, and medical assessments. ■■ Provide assessment information as member of interdisciplinary teams for deaf and hard of hearing students and those with auditory processing disorders. ■■ Assist educational team members in making referrals for additional medical care, educational assessments, and specialized audiologic assessments if not available within the school facilities. Habilitation and educational management ■■ Analyze classroom noise and acoustics and recommend strategies for improving acoustic accessibility in the learning environment. ■■ Select, fit, monitor, and manage amplification used in the educational environment. ■■ Collaborate in the development and implementation of evidence-based treatment plans to facilitate communication competence using technology, auditory skill development, communication repair strategies, speechreading, and other visual communication supports. ■■ Identify accommodations to facilitate access to education for students with hearing difficulties who are in general education settings and/or in special education settings. ■■ Serve as a member of the Individual Family Service Plan (IFSP), Individualized Education Program (IEP), and instructional teams responsible for the educational plans for deaf and hard of hearing children. ■■ Collaborate in the development and implementation of an appropriate 504 plan for access to general education instruction when special education services are not recommended. ■■ Collaborate in the application of research-based protocols to measure ongoing progress and outcomes for students receiving aural habilitation within the educational environment. Amplification, cochlear implants, and assistive technology ■■ Select, fit, monitor, and manage personal and classroom amplification and remote microphone hearing assistance technology (RM HAT) used in the educational environment. ■■ Maintain a collaborative working relationship with cochlear implant program audiologists, manufacturers, families, and school personnel to facilitate appropriate referrals and follow-up for cochlear implant evaluations and/or use. Hearing loss prevention ■■ Provide comprehensive hearing conservation curricula within the school environment. ■■ Provide for education about and access to hearing protection devices. ■■ Collaborate with other school professionals to develop materials and design activities related to hearing conservation. ■■ Provide current resources and materials for school personnel regarding state and federal noise protection standards. (Continues )

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Roles and Responsibilities of Educational Audiologists

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TABLE 2–1  (Continued ) Counseling ■■ Provide information and support to students, families, caregivers, and educational personnel related to the educational and psychosocial aspects and impact of reduced hearing. ■■ Facilitate a school-based learning and social environment that fosters communication access for deaf and hard of hearing students. ■■ Provide information and coaching to assist deaf and hard of hearing students in their development of self-advocacy and selfdetermination skills. ■■ Facilitate communication among families of deaf and hard of hearing children and youth. ■■ Provide information to educators, families, and students regarding evidence-based benefits and limitations of hearing aids, cochlear implants, and assistive devices, as well as use and maintenance of this technology. ■■ Make appropriate referrals to address counseling needs beyond the student’s hearing loss.

Assessment A key responsibility of educational audiologists is providing comprehensive and educationally relevant audiology evaluations, including functional listening performance and the assessment of central auditory functioning. Although traditional audiology assessment is a primary requirement, we strongly believe that the responsibility of educational audiologists is to perform functional assessments of listening skills and support optimal communication access. These assessments should be contingent on the student’s various learning environments and, therefore, also require an assessment of the auditory and visual aspects of the classroom facilities. Analysis of the interactions of hearing and listening abilities is critical for communication and instructional access, and subsequent determination of accommodations and other intervention considerations. Educational audiologists must make appropriate referrals and be able to recognize and discuss the relationship of atypical hearing or a central auditory processing issue to the student’s overall functioning and to help determine when the hearing status or auditory processing concern is educationally significant. The importance of classroom acoustics has gained recognition for its role in supporting learning for all children. With the current legislative requirements for documenting mastery of academic material by all students, the need and opportunity for educational audiologists to increase their

What Is an Educationally Significant Hearing Loss (ESHL)? Any hearing level that potentially interferes with access to classroom instruction and impacts a child or youth’s ability to communicate, learn, and develop peer relationships.

involvement in this area has increased substantially. Educational audiologists often take the lead in performing classroom acoustic measurements and in disseminating information on ways to improve acoustics in listening and learning environments. Educational audiologists should also promote appropriate visual access that considers lighting and positioning of students to reduce glare and other visual barriers (NASDSE, 2018, p. 41). School-based audiologists should collaborate with school facilities personnel, architects, technology personnel, acousticians, parents, and other members of the educational team to advocate for educational facilities that meet the current American National Standards Institute (ANSI, 2010) standards as well as universal design for learning (UDL) instructional practices. Issues related to assessment are addressed in detail in Chapter 5, Assessment; Chapter 6, Auditory Processing Deficits; and Chap­ ter 7, Classroom Acoustics and Other Learning Environment Considerations.

Habilitation Habilitation or intervention services can include a broad array of direct and indirect support for students with hearing or listening challenges. Although not all educational audiologists assume responsibility for providing direct intervention services to deaf and hard of hearing students, educational audiologists have a critical role in habilitation that includes working with the educational team to determine the services that are needed and to ensure that all identified services are provided and implemented as intended. Frequently, educational audiologists consult with other school- and nonschool-based professionals who are providing services to assist with communication access and classroom accommodations and to ensure that the services are appropriate. Direct services may focus on any or all of the following: ■■ ■■

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Chapter 2

Note. From Educational Audiology Association (2019), Educational audiology scope of practice; American Speech-Language-Hearing Association (2018), Scope of practice in audiology; American Speech-Language-Hearing Association (2002), Guidelines for audiology service provision in and for schools; National Association of State Directors of Special Education (2018), Optimizing outcomes for students who are deaf or hard of hearing: Educational service guidelines, 3rd ed.

language development; speechreading and other visual communication supports;

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Chapter 2

auditory and listening skill development; communication strategies; hearing aid orientation; use and care of personal hearing instruments and hearing assistive technology; self-determination and advocacy about hearing and communication access needs; and/or informational counseling.

More information on implementing habilitation services is contained in Chapter 9, Case Management and Habilitation.

Hearing Loss Prevention Chapter 2

One of the responsibilities of educational audiologists is educating parents, teachers, students, and school staff about all levels of hearing and ways to prevent hearing loss. This education may be accomplished through in-service programs for teachers, development and implementation of noise education curricula, direct instruction to students, and monitoring of noise levels during various school activities. Prevention activities often have a lower priority than other responsibilities, but this information is important and can be a means of increasing the awareness of school personnel about all educational audiology services. More information on hearing loss prevention strategies and activities is contained in Chapter 12, Prevention of Noise-Induced Hearing Loss and Tinnitus in Youth.

Counseling and Coaching Counseling includes support for students, parents, and school personnel regarding a child’s identity including as a person with reduced hearing. Identity, self-esteem, emotional and social development, self-determination, and selfadvocacy all contribute to a student’s wellness and ability to be responsible for his or her hearing and communicationrelated needs. Students need to be fully involved in the management of their own hearing status if positive outcomes in these areas are to be achieved. The educational audiologist should be a key provider of information and coaching related to students’ knowledge of hearing levels, amplification, and communication challenges within school, home, and community environments. And when partnering with parents, teachers, deaf or hard of hearing mentors, and other school personnel, educational audiologists can also contribute to the development of identity, self-esteem, selfdetermination, and self-advocacy skills to support students in becoming better advocates for their own communication needs. In addition, educational audiologists can often facilitate networking and group activities with other deaf and hard of hearing peers, a critical social and emotional component of identity and overall wellness. The role of the educational audiologist as a provider of wellness and counseling support is discussed in more detail in Chapter 10, Supporting Wellness and Social-Emotional Competence.

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Educational audiologists must work closely with each child’s family to provide support and, when necessary, IEPbased parent coaching, counseling, and training services. Family-centered early intervention now is the norm for infants and toddlers in the United States, but families often become less involved in their children’s education as the years go on. It is important to keep parents involved because they have knowledge about their children that can result in a more productive educational program with improved outcomes. Additionally, parents often become primary case managers during periods when school personnel are not available, such as during the summer months and holiday vacations. Educational audiologists increasingly must engage and coach families to empower them to more fully participate in their children’s education and to use their resources to support their children’s communication development and educational progress. When engaging families, educational audiologists must be sensitive to culture and norms. Families may include only a single parent, or there may be a large extended family ac­­ tively involved with the child. There are many various socioeconomic and cultural differences, including the unique considerations associated with Deaf culture as well as those for families from other countries. Educational audiologists must be aware of various parent/family options and preferences regarding communication modes, programming and services, educational placements, amplification, and other issues. It is critical to provide impartial information in a nonjudgmental manner to parents and to support their decisions. A final aspect of counseling is the support to school personnel, including teachers, specialized instructional support personnel (SISP), administrators, and paraprofessionals to ensure that appropriate educational services are delivered to and accessible for each deaf or hard of hearing student. The educational audiologist is a member of the educational team who evaluates and provides services for students with hearing and listening challenges. The educational audiologist can provide information and coaching to the classroom teacher and other professionals who work with each student regarding the implications of the hearing status, accessibility issues, and potential management strategies. These issues are addressed more completely in Chapter 3, Partnering with Families; Chapter 9, Case Management and Habilitation; Chapter 10, Supporting Wellness and Social-Emotional Competence; Chapter 11, Developing Individual Plans; Chapter 13, Supporting the Educational Team; and Chap­ ter 14, Educational Considerations for Students Who Are Deaf or Hard of Hearing.

Amplification, Cochlear Implants, and Other Assistive Technology The area of hearing instruments and other assistive listening technology is a major responsibility for educational audiologists. The need for audiology support services in the

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Roles and Responsibilities of Educational Audiologists

ETHICAL CONSIDERATIONS Codes of ethics are a guide for professional behavior, and educational audiologists may practice under one or more formal codes that have been adopted by professional organizations (e.g., AAA, 2018; ASHA, 2016a; Council for Exceptional Children, Division for Communication, Language and Deaf/Hard of Hearing, 2018), codes attached to state licensure laws, or guidelines found within state standards of practice (Seaton, 2001). Some of the areas where ethical concerns may impact the practice of audiology in the schools include the following: ■■

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compliance with federal and state laws, regulations, and policies; relations among private and educational audiologists related to the dispensing and management of technology; issues of confidentiality; conflicts of interest; restrictions on information provided to families and caregivers; referral procedures; perceived pressure to compromise recommendations for or against services and technology;

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lack of qualified personnel and/or financial resources to support services or technology; and personal and professional biases.

Our ethical codes can provide benchmarks for use in monitoring and evaluating the practice of audiology in the schools. Questions of ethics often have no “right or wrong” answers, but considering relevant ethical practice statements can help guide our thinking as we provide services to students and their families. Increased awareness of Codes of Ethics that impact the practice of audiology is critical for both educational audiologists and other school professionals responsible for administering and supervising audiology services in the schools. Ethics, personal belief systems, and bias are discussed further in Chapters 3 and 15. Chapter 2

school environment continues to rise as the number of students wearing technology and the variety of personal and assistive technologies worn by students increases. Though technology advancements may streamline the functioning of these devices, the complexity for audiologists and teachers is the variety of technologies they must manage, including hearing aids, cochlear implants, bone-anchored hearing systems, FM, DM, Bluetooth, streaming, and looping, as well as the connectivity between these personal and assistive devices with other classroom technologies. More information about the role of educational audiologists with students using cochlear implants can be found in the EAA position statement, Educational audiologists and cochlear implants (EAA 2005). Although either clinical audiologists or educational audiologists may make recommendations about a student’s use of hearing aids, cochlear implants, bone-anchored hearing devices, tactile devices, and other amplification systems, the educational audiologist is usually the individual responsible for ensuring that these devices are functioning properly and are being used correctly and appropriately in the classroom (American Academy of Audiology, 2008 EAA, 2014). The educational audiologist is also the person who typically makes recommendations for the use of personal DM/ FM systems, classroom audio distribution systems (CADS), or other remote microphone technology and who has the responsibility for monitoring device function in the learning environment. This topic is covered in more detail in Chapter 8, Hearing Instruments and Remote Microphone Technology.

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EDUCATIONAL  AUDIOLOGY SERVICE DELIVERY MODELS Educational audiology services can be delivered in various ways within a school district. Several different models have been discussed over time, but most are merely modifications of two basic models: ■■ ■■

school based and contractual agreement.

Both models can be used to provide effective educational audiology services in schools, and it may be possible that a district will find it beneficial to provide services using a combination of the two models. Neither of these models is superior to the other, but they each have specific advantages and disadvantages (see Table 2–2 for a comparison of the two models).

School-Based Audiology Services In a school-based model of services, the educational audiologist typically is a direct employee of a single school district or multidistrict education agency. Most school-based audiologists are relatively autonomous in defining their positions and are therefore able to include comprehensive educational audiology services in their job descriptions. Because schoolbased audiologists are employees of school systems, they are peers of teachers and other school personnel and are perceived as providing services within the system rather than as an outsider. Scheduling flexibility for consultation and follow-up can also be an advantage of this model. Although payment for school-based audiologists frequently is based on an educational salary schedule, many systems’ salary schedules are based on education and experience, with an increment for advanced degrees and/or professional certification. Benefits, such as health insurance and retirement plans, also are typically part of the employment package. A major disadvantage is that many districts assume that the school-based

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TABLE 2–2  Comparison of School-Based and Contractual Agreement Service Delivery Models School-Based Audiology Services ■■ ■■

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Direct employee, typically for one employer Benefits (e.g., insurance, retirement, staff development) similar to other school employees included Services are typically comprehensive based on job description Relatively autonomous for service and scheduling decisions, dependent on administrative knowledge and support Peer of other school employees; perceived as “insider” with increased opportunities for collaboration District typically purchases and maintains audiological equipment and related materials Overall cost to district may be less per service Possible to implement when part of a regional cooperative Often less cost-effective in small, rural systems with smaller student populations unless system belongs to regional cooperative that employs audiologist(s) Caseload and geographic area may be large for regional cooperative Unanticipated student needs may be addressed more quickly by school-based employee Scheduling flexibility for consultation and follow-up Staff meeting attendance may be required

audiologist can provide services to an infinite number of students. This model is effective only if the audiologist’s caseload is reasonable. The EAA supports a target ratio of one full-time equivalent (FTE) educational audiologist for every 10,000 students served by the LEA or multidistrict agency (i.e., regional cooperative). Workload factors such as extensive travel time or time-intensive services (e.g., direct intervention; services to infants, toddlers, students with multiple disabilities; service provision to regional or selfcontained programs designed for multiple students who are deaf or hard of hearing) may result in the need for adjustment of this ratio (EAA, 2009). The ASHA Guidelines for Audiology Service Provision in and for Schools (2002) suggests that there should be a ratio of at least one FTE audiologist for every 10,000 children (birth through 21 years of age). A number of factors, such as geographical coverage and travel time, numbers of students with hearing loss beyond the expected prevalence, and secretarial, scheduling, and computer support, are identified by ASHA as time-intensive services that can reduce the caseload ratio of one per 10,000 students.

Contracted Audiology Services A school district may choose to provide educational audiology services using a contractual agreement. In this instance, the district contracts with the audiologist to perform specified

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Contract employee No employment benefits provided Contract typically specifies number of hours and/or days per week required Services may be limited by scope of contract Can be difficult to anticipate and address student needs that require contract changes Considered an “outside expert”; collaboration with teachers may be challenging Caseload can be specified in contract District usually not responsible for diagnostic audiological equipment Lower capital outlay Higher cost per service May be appropriate for small, rural systems when shared services/ regional cooperatives not available Contracts with individual systems belonging to regional educational cooperatives may be viewed as financially inequitable and result in less efficient service delivery to students than contracting through the cooperative Staff meetings and staff development may not be covered in contract

services for students. This model may be more feasible for the school district and may be the only means of obtaining audiology services in small or rural districts. If the contract is comprehensive, the services provided to the students may not differ from those provided by school-based audiologists. However, many districts limit services in their contracts so that most of the services related to the educational support for deaf or hard of hearing students are addressed minimally, if at all. Also, with this model, educational audiologists often are viewed as “outside experts,” and their effectiveness to collaborate with teachers may be compromised. Audiologists providing contracted audiology services should emphasize to administrators that a full range of audiology services is required by IDEA (2004). Differences between educational and clinical audiology services may need to be clarified as the contract is being developed (Table 2–3). In addition to hearing assessments, activities such as classroom observations, teacher collaboration, attendance at IEP or IFSP meetings, equipment maintenance and repair, and in-service should be specified in the contract. The Suggested and Shared Roles checklist (Appendix 2–A) is a tool to help guide service delivery by various members of the team. Guidelines for developing contracted educational audiology services have been developed by the EAA in 2012 and are available online (see recommended resources at the end of this chapter).

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Roles and Responsibilities of Educational Audiologists TABLE 2–3  Educational Audiology and Clinical Audiology Practices

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Identify hearing status for children and youth Collaborate with local and state early hearing detection and intervention (EHDI) programs regarding follow-up and intervention Participate in the development and oversight of school hearing screening programs and other programs for the prevention of hearing loss Assess hearing status and interpret educational implications and impact of atypical results Make appropriate referrals for medical attention and management Collaborate with private-sector/community-based audiologists and other professionals relative to students’ educational needs Evaluate hearing abilities and auditory skill development to determine hearing function in various communication and learning settings Counsel students, family, and educational team regarding educational impact of identified hearing loss Select, fit, verify, validate, and monitor personal amplification and hearing assistance technology for educational settings Ensure that amplification is working properly in schools Measure acoustics in classrooms and other learning environments Identify instructional modifications and accommodations to facilitate access to education in all school settings Consult with students, teachers, parents, and other relevant staff regarding hearing, amplification, and accommodation needs Participate as a member of educational team for students with auditory needs Provide or assist with (re)habilitative needs within learning environment Assist with transition planning and support

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Identify hearing loss at earliest age in clinical/hospital settings Collaborate with local and state EHDI programs regarding screening, diagnosis, and follow-up Collaborate with community health agencies and volunteer organizations to provide adult hearing screening programs Administer and provide programs for the prevention of work-related hearing loss Administer and interpret clinical case history, behavioral, electroacoustic, and electrophysiologic measures of the peripheral and central auditory, balance, and other related systems to detect the presence of hearing, balance, and other related disorders Provide cerumen management Evaluate, select, fit, verify, validate, dispense, and monitor performance of a variety of technology interventions for hearing, balance, and other related disorders Assist with counseling and (re)habilitative needs related to auditory and vestibular disorders Promote self-advocacy for personal needs or systems change Provide strategies to address other related disorders (e.g., tinnitus, misophonia) Provide individual counseling and public education about the benefits and/or limitations of various classes of devices and technology Provide assistance with acoustic management of large community meeting facilities (e.g., theaters, churches, entertainment arenas) Communicate with physicians, families, and referral sources Activities typically provided in clinic and/or hospital facilities

Chapter 2

Educational Audiology

Note. From AAA Standards of Practice (2012),  ASHA Scope of Practice (2018), EAA Recommended Professional Practices for Educational Audiology (2009).

Combined School-Based and Contractual Agreement At times, it may be advantageous for a school district or LEA to use a combination of both school-based and contractual agreement services. This model can be particularly useful when the school-based audiologist is not able to provide services to all of the students within the district or when an audiologist with specialized skills or equipment is needed. The contracted audiologist may provide comprehensive services to specified students within the district, such as those who live in a particular geographical area or those with specific disabilities and/or equipment needs (e.g., auditory brainstem assessment or cochlear implant programming). Optionally, the contracted audiologist may provide specified services (e.g., auditory processing assessments) to all students within

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the district. For this model to work effectively, both the school-based and the contracted audiologist must have wellarticulated responsibilities, a clear understanding of what the other is doing, and an ability to collaborate so that comprehensive services are provided without duplication. Additional information to assist in comparing schoolbased audiology with contractual audiology services, including strategies for estimating cost–benefit and workload assessment can be found in Chapter 16, Program Development, Evaluation, and Management.

Telepractice An evolving method for the delivery of educational audiology services is telepractice/teleaudiology/telehealth, the remote delivery of services through an Internet system

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in which the audiologist delivering the service is not onsite with the individual receiving the services. This type of contracted arrangement has been used for remote programming of cochlear implants used by children as well as adults (Franck, Zerfoss, & Pengelly, 2006; Hughes, Sevier, & Choi, 2018) and can be an efficient alternative to multiple programming appointments requiring students to leave their school locations. Additional services delivered remotely include diagnostic testing, hearing aid fittings and equipment troubleshooting, classroom observations, and coaching. Telepractice is beginning to be implemented and validated as a system for use in early hearing detection and intervention (EHDI) programs as well as with local school systems for additional auditory device services (Angley, Schnittker, & Tharpe, 2017; Steuerwald, Windmill, Scott, Evans, & Kramer, 2018). Educational audiologists using or considering the use of telepractice should familiarize themselves with current regulations involving the electronic transfer of patient information (e.g., Health Insurance Portability and Accountability Act [HIPAA], Family Educational Rights and Privacy Act [FERPA], see Chapter 1). For additional discussion of potential benefits, limitations, trends, and research related to telepractice, educational audiologists are referred to the following documents: AAA (2015), Introduction to telemedicine (available from https://www.audiology.org/prac tice_management/resources/introduction-telemedicine) and ASHA (2014), Telepractice practice portal (available from https://www.asha.org/Practice-Portal/Professional-Issues /Telepractice/). In addition, Chapter 17, Reflections and Future Directions, includes a more detailed discussion by an educational audiologist who is currently providing school services remotely.

ESTABLISHING AND EXPANDING EDUCATIONAL  AUDIOLOGY SERVICES IN THE SCHOOLS Although educational audiologists have been employed in school systems for many years, there are still many areas in which educational audiology services are minimal or nonexistent (Richberg & Smiley, 2009). A few states have adopted guidelines related to the practice of educational audiology (e.g., Georgia, Colorado, Minnesota), but only Colorado’s practice standards specify a caseload requirement of one audiologist for every 10,000 students in a school system, as recommended by the EAA (2009) and ASHA (2002). A workload approach that involves documenting and analyzing time spent providing educational audiology services including direct and indirect activities necessary to support students’ needs is preferred to a caseload approach targeting student populations or a specific number of identified deaf or hard of hearing students. It is imperative that educational

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audiologists document outcomes for services provided in a format that is related to school district goals and objectives (e.g., classroom accommodations that have facilitated successful performance on standardized assessments as well as for general education classroom instruction). See Chapter 16, Program Development, Evaluation, and Management, for guidance on creating and expanding services, workload analysis, and outcomes, and Chapter 15, Collaborative School-Community Partnerships, for information on increasing awareness of and advocating for educational audiology services.

Reimbursement for Educational Audiology Services A number of school systems have implemented third-party reimbursement from Medicaid for audiology as a healthrelated service provided to students under IDEA (2004). This is permitted by the current guidelines established by the Centers for Medicare and Medicaid Services (CMS), provided that the service is ■■ ■■ ■■

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provided to Medicaid-eligible children; medically necessary; delivered and claimed in accordance with all other federal and state regulations; and included in the state Medicaid plan.

Although Medicaid has national guidelines, each state has the authority to determine the type, amount, duration, and scope of services; determine state eligibility standards; set rates of payments; and administer its own program. Educational audiologists who bill Medicaid for their services through a school district must be qualified as Medicaid providers in their state and must be knowledgeable about their individual state’s current Medicaid plan. More detailed information on Medicaid regulations and reimbursement requirements related to school services is available from the American Speech-Language-Hearing Association (see Resources).

Dispensing Personal Hearing Instruments Some school districts have limited provisions for dispensing of personal hearing instruments as a part of the educational audiology program as these devices must be classified as assistive technology. Typically, this service is undertaken to address an educational need and most often occurs when insurance, Medicaid, or income issues prevent a child from getting hearing aids in a timely manner. Most schools retain the instruments as school property, and depending on district policy, they may or may not go home when the student is not attending school. We recommend that school-based audiologists considering dispensing should familiarize themselves with the legal and ethical implications of setting up such a program in their individual communities and school districts.

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Roles and Responsibilities of Educational Audiologists

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Cerumen Management

Support for Early Hearing Detection and Intervention Although it is incumbent on all educational audiologists to be knowledgeable and supportive of early hearing detection and intervention practices in their local areas, many educational audiologists play a larger role in the identification and follow-up services for infants and toddlers with reduced hearing. IDEA 2004 requires each state to designate a lead agency to oversee programs and services for infants and toddlers with disabilities and follow the federal eligibility requirements that are noncategorical under Part C (see https:// infanthearing.org/stateguidelines/index.php). Each state may provide further eligibility guidance so long as it meets the federal requirements. As a result, educational audiology services can and do vary widely between states and among districts within many states. Audiology is listed as an early intervention service in the federal statute,3 and regulations for audiology services under IDEA Part C4 vary slightly from those listed under Part B (see Table 2–4). Where the designated Part C agency is the state department of education, roles and responsibilities may fall in line with those described earlier in this chapter.

“Audiologists who are employed in school settings have an opportunity as well as responsibility to promote early detection and intervention of hearing loss.” (EAA, 2002, p. 1)

If the responsible agency for birth to 3 years of age is not the department of education, at a minimum, the educational audiologist has the responsibility to (a) collaborate with local early intervention programs and providers, (b) provide support to families during the identification and intervention process, and (c) serve as a member of and facilitator for the transition team as the child and family move to educational services under IDEA Part B. If the child’s placement is to fill a federally funded slot for students with disabilities or a state-funded at-risk program placement in a regular daycare or preschool setting, the educational program is required to provide the necessary support services. If the infant or toddler is placed in a daycare or other nonpublic preschool setting, the educational audiologist should, at a minimum, observe the child’s functioning for relevant auditory information and functional listening skills and serve as a resource for amplification equipment (both personal and classroom remote microphone sound distribution systems), appropriate curricula and materials for maximizing auditory learning, and other habilitation needs. (See Chapter 9, Case Management and Habilitation, for more detail concerning classroom support applicable to daycare environments.) The EAA’s position statement Early detection and intervention of hearing loss: roles and responsibilities for educational audiologists (2002) identifies potential roles, responsibilities, and activities for educational audiologists with the infant and toddler population. Also included is a strategy for discussing communication features, as distinct from communication modes or methodologies, and the educational audiologist’s role in facilitating service provision in natural environments. Chapter 20 in the EHDI e-book 2019 (http://infanthearing.org/earlyintervention/index.html) describes educational audiology roles and responsibilities under IDEA Part C. Appendix 2–B summarizes information for use when identifying and implementing early intervention roles and responsibilities for educational audiologists within their local communities. An additional resource document developed by ASHA emphasizes three co-occurring roles for audiologists serving the infant and toddler population (diagnostician, counselor,

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Although cerumen management is included in the audiologist’s professional scope of practice, this service typically is not provided in the educational setting (see ASHA, 2016b, for state information). However, some cerumen removal may be necessary to conduct certain assessments such as acoustic immittance and probe-microphone measurements or as part of hearing aid or HAT use. Educational audiologists who wish to consider adding cerumen management to their practice should check with their state licensure and certification requirements (where applicable) as well as their employers and legal counsel to determine if there are any legal requirements or restrictions that would apply. Any educational audiologist planning a cerumen management program also should develop a written protocol that includes procedures for obtaining parental permission and the process for making referrals to other medical professionals when warranted. Participation in continuing education workshops or conference sessions that provide information on type of equipment, instruments, and infection control in addition to offering hands-on training in cerumen management is strongly recommended for those who have not completed this training in their educational program. Finally, before implementing a program in cerumen management within the educational setting, professional liability coverage should be discussed with the school system administration and legal counsel (Lowell & Valdes, 2010).

3

20 U.S.C.§1432, Definitions (4)(E)(iii). CFR §303.13 (b)(2)(i-vi).

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TABLE 2–4  Descriptions of Audiology Services Under the Individuals With Disabilities Education Act 2004

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Part C §303.13 (b)(2)(i-vi)

Part B§300.34(c)(1)(i-vi)

(2) Audiology services include — (i) Identification of children with auditory impairments, using a­ trisk criteria and appropriate audiologic screening techniques; (ii) Determination of the range, nature, and degree of hearing loss and communication functions, by use of audiological evaluation procedures; (iii) Referral for medical and other services necessary for the habilitation or rehabilitation of an infant or toddler with a disability who has an auditory impairment; (iv) Provision of auditory training, aural rehabilitation, speech ­reading and listening devices, orientation and training, and other services; (v) Provision of services for prevention of hearing loss; and (vi) Determination of the child’s individual amplification, including selecting, fitting, and dispensing appropriate listening and vibrotactile devices, and evaluating the effectiveness of those devices.

(1) Audiology includes— (i) Identification of children with hearing loss; (ii) Determination of the range, nature, and degree of hearing loss, including referral for medical or other professional attention for the habilitation of hearing; (iii) Provision of habilitative activities, such as language habilitation, auditory training, speech reading (lip-reading), hearing evaluation, and speech conservation (iv) Creation and administration of programs for prevention of hearing loss; (v) Counseling and guidance of children, parents, and teachers regarding hearing loss; and (vi) Determination of children’s needs for group and individual amplification, selecting and fitting an appropriate aid, and evaluating the effectiveness of amplification.

and case manager or “care coordinator”) and delineates the knowledge and skills necessary for each role (ASHA, 2006). As children who are deaf or hard of hearing increasingly are identified and served through early intervention programs, it is critical for educational audiologists to include information such as the EAA and ASHA documents in in their job descriptions and to disseminate this information to EHDI personnel, families, and clinical audiologists in their area. Finally, educational audiologists can facilitate the IFSP process and the transition from services under Part C to those under Part B by providing information regarding resources and all support options available to deaf and hard of hearing infants and young children. The Joint Committee on Infant Hearing recommends including quarterly educational audiology services at a minimum as part of the preschool transition plan and further emphasizes that children who transition with ageappropriate language and communicative skills should continue to be monitored and supported (JCIH, 2019). See the following chapters for more information about educational audiology services for children birth through age 3 years: ■■

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identification (Chapter 4, Hearing Screening and Identification); determination of the range, nature, and degree of hearing loss (Chapter 5, Assessment); referral for other services as needed (Chapter 5, Assessment); provision of aural rehabilitation and listening device orientation (Chapter 9, Case Management and Habilitation, and Chapter 8, Hearing Instruments and Remote Microphone Technology); hearing loss prevention services (Chapter 3, Partnering with Families; Chapter 4, Hearing Screening and Iden-

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tification; and Chapter 12, Prevention of Noise-Induced Hearing Loss and Tinnitus in Youth); services related to amplification and hearing assistive technology (Chapter 8, Hearing Instruments and Remote Microphone Technology); and counseling (Chapter 3, Partnering With Families).

TRAINING FOR EDUCATIONAL AUDIOLOGISTS To be qualified for all of the responsibilities described in this chapter, it is obvious that educational audiologists must have training beyond basic audiology coursework. Early surveys routinely indicated that practicing educational audiologists believed they were inadequately prepared to meet the responsibilities they have in the schools, especially in areas such as amplification, educational management of deaf and hard of hearing children, mainstreaming, auditory (re)habilitation, working with special populations, sign language, and counseling (Blair, Wilson-Vlotman, & Von Almen, 1989; Seaton, Von Almen, & Blair, 1994; Wilson-Vlotman & Blair, 1986). Additionally, two-thirds of the respondents to the survey conducted by Seaton, Von Almen, and Blair (1994) stated that an externship in an educational setting would have been helpful. In recognition of the deficiencies currently existing in the training of educational audiologists, the EAA-approved Minimum competencies for educational audiologists was published initially in 1994. An updated version (2009) is available currently as a downloadable handout from http:// edaud.org. These competencies focus on the knowledge,

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skills, and abilities necessary to provide effective comprehensive audiology services in the schools. Although many of the competencies are also necessary for clinical audiologists, competency in the following areas are unique to the educational setting: ■■

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educational referral, follow-up procedures, and special education eligibility requirements; evaluation of the need for, selection, and maintenance of personal DM/FM and classroom audio distribution systems and other RM HAT used in educational environments; the structure of the learning environment, including classroom acoustics and implications for learning; IFSP and IEP planning process and procedures, including interpretation of auditory assessment results and their implications, educational options, and legal issues and procedures; consultation and collaboration with classroom teachers and other professionals regarding the relationship of hearing and reduced hearing to the development of academic and psychosocial skills; participation in team management of communication treatment; knowledge of the various communication approaches used by deaf and hard of hearing individuals and familiarity with American Sign Language and Deaf culture; implementation of in-service training and coaching for educational staff and support personnel; knowledge of school systems, multidisciplinary teams, and community and professional resources; and knowledge of laws, regulations, and policies governing general and special education.

SUMMARY The roles and responsibilities of educational audiologists in the total management of deaf or hard of hearing students are quite comprehensive (see Appendix 2–C). Unfortunately, administrators, other school personnel, and parents often are not aware of the need for educational audiologists, and educational audiology services frequently are not available or are underused. There are many ways that educational audiology services can be delivered in a school system, but it is important for us to recognize what we can do to advocate for our services. It is possible to enhance audiology services in the schools, but to do so takes a planned, consistent effort on the part of educational audiologists. The changes required are not easy to accomplish, but they are necessary to ensure comprehensive services for all deaf and hard of hearing students and other children and youth with hearing and listening challenges in their educational environments.

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The EAA also recommended that all audiologists employed in the schools complete an internship in a school setting under the supervision of an educational audiologist, preferably a full-time experience lasting at least 6 weeks. These recommendations have been used to encourage university training programs to include relevant curricula for educational audiologists and to inform school administrators about the special knowledge, skills, and abilities of educational audiologists. English and Vargo (2006) provide encouraging results regarding the status of educational preparation for audiologists working with school-aged children and youth. Of 56 AuD programs surveyed, the majority reported their programs include learning objectives related to the recommended areas, but only 45% of the programs surveyed required a course in educational audiology. A more recent survey (Dillmuth-Miller, 2016) found that 30 of 71 (42%) AuD programs reported offering a course in educational audiology, while the remaining programs (58%) included educational audiology topics in other courses (e.g., pediatric audiology, aural habilitation). Another promising strategy reported by the Colorado Department of Education describes their licensure requirements for educational audiologists that align entry-level knowledge and skills with the IDEA definition of audiology plus an additional area of ethical conduct (https://www.cde.state.co.us/cdeprof/schoolau diologistendorsementrules). An 8-week FTE practicum or internship is also required for educational audiology licensure in Colorado, and it is hoped that other states requiring a state credential will consider this requirement. There continues to be a need for standardization of educational audiology coursework and content within AuD programs.

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Roles and Responsibilities of Educational Audiologists

SUGGESTED READINGS AND RESOURCES American Academy of Audiology. (2004). Scope of practice. Retrieved from https://audiology.org/publications-resources /document-library/scope-practice American Academy of Audiology. (2012). Standards of practice. Retrieved from https://www.audiology.org/sites/default/files /documents/StandardsofPractice.pdf American Speech-Language-Hearing Association. (2009). Guidelines for audiology service provision in and for schools [Guidelines]. Retrieved from https://www.asha.org/policy American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of Practice]. Retrieved from https://www.asha.org/policy American Speech-Language-Hearing Association. (n.d.). Schoolbased medicaid services: Audiology. Retrieved from https:// www.asha.org/practice/reimbursement/Medicaid/SchoolBased ServicesAUD/

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American Speech-Language-Hearing Association. (n.d.). Telepractice Overview. https://www.asha.org/Practice-Portal/Pro fessional-Issues/Telepractice/ Anderson, K., & Arnoldi, K. (2011). Building skills for success in the fast-paced classroom. Hillsboro, OR: Butte Publications. Davis, J. (2002). Our Forgotten Children: Hard of Hearing Pupils in the Schools (3rd ed.). Washington, DC: Shhh Publications. Colorado Department of Education: Standards of Practice for Audiology Services in the Schools (n.d.) “Rubric for Evaluating Colorado’s Specialized Service Professionals: Audiologist Simulation.” Retrieved from http://www.cde.state.co.us /educatoreffectiveness/audsimulation Colorado Department of Education: Standard Requirements for All Colorado Initial Special Services Licenses (n.d.). Retrieved from http://www.cde.state.co.us/cdeprof/licensure_ssp Educational Audiology Association (EAA). Retrieved from http:// www.edaud.org/position-statements/

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Educational Audiologists and Cochlear Implants (2005) Recommended Professional Practices for Educational Audiology (2009) Guidelines for Developing Contracts for School-based Audiology Services (2012) Educational Audiology Association: Guidelines of the Consensus Panel on Support Personnel in Audiology (1997)

English, K. (2018). Audiologic rehabilitation services in the school setting. In Schow, R., & M. Nerbonne (Eds.), Introduction to audiologic rehabilitation (7th ed., pp. 217–246). New York, NY: Pearson Publishing. Johnson, C. D. (2011). A call for outcomes measurement for school-based audiology services. Hearing Journal, 64(10), 30–32. Johnson, C., Cannon, L., Oyler, A., Seaton, J., Smiley, D., & Spangler, C. (2014). Shift happens: Evolving practices in schoolbased audiology. Journal of Educational Audiology, 20, 1–15.

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Macione, M., Johnson, C. D., & Sanders, S. (2019). The role of educational audiologists in the EHDI Process. In National Center for Hearing Assessment, The EHDI e-book: A resource guide for early hearing detection and intervention. Retrieved from http://www.infanthearing.org Madell, J. (2013, May). Educational audiology: From observation to recommendation. AudiologyOnline, Article 11853. Retrieved from http://www.audiologyonline.com/ Madell, J., & Flexer, C. (2013). Pediatric audiology: Diagnosis, technology and management (2nd ed.). New York, NY: Thieme Medical Publishers. Madell, J., & Flexer, C. (2018). Maximize children’s school outcomes: The audiologist’s responsibility. Audiology Today, 30(1), 18–26. National Association of State Directors of Special Education (NASDSE). (2018). Optimizing outcomes for students who are deaf or hard of hearing: Educational service guidelines. Alexandria, VA: NASDSE. National Center for Hearing Assessment and Management (NCHAM) EHDI e-book (2019). Chapter 20: The Role of Educational Audiologists in the EHDI process. Retrieved from http://infanthearing.org/ehdi-ebook/ Northern, J., & Down, M. (2014). Hearing in children (6th ed.). San Diego, CA: Plural Publishing. Richberg, C., & Smiley, D. (2011). School-based audiology. San Diego, CA: Plural Publishing. Roeser, R. J., & Downs, M. P. (2004). Auditory disorders in school children: The law, identification, remediation (4th ed.). New York, NY: Thieme Medical Publishers. Schraeder, T. (2019). The 3:1 model—A workload solution. The ASHA Leader, 34(5), 36–37. Tye-Murray, N. (2018). Foundations of aural rehabilitation: Children, adults, and their family members (5th ed.). San Diego, CA: Plural Publishing. [section on school services]

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APPENDIX

2–A Supporting Students who are Deaf and Hard of Hearing: Shared and Suggested Roles of Educational Audiologists, Teachers of the Deaf and Hard of Hearing, and Speech-Language Pathologists (Approved by the Board of Directors of the Educational Audiology Association February 2018)

Educational audiologists, teachers of the deaf and hard of hearing, and speech-language pathologists are critical partners on the school education team. Together, they address the needs of students who are deaf and hard of hearing and promote language and communication access that is essential for participation and learning in today’s educational environments. The Individuals with Disabilities Education Act (IDEA), Section 504 of the Rehabilitation Act, and the Americans with Disabilities Act (ADA) all contain regulations pertinent to the services and accommodations contained in this guidance document.

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Language and Communication Regulations (Title II and IDEA) Title II of the ADA includes the following requirements for schools: ● Communication for students who are deaf and hard of hearing must be “as effective as communication for others” [ADA Title II 28 C.F.R. §35.160 (a)(1)]. ● Provision of appropriate aids and services “affording an equal opportunity to obtain the same result, to gain the same benefit, or to reach the same level of achievement as that provided to others” [ADA Title II 28 C.F.R. §35.130 (b)(1)(iii)]. ● Students who are deaf and hard of hearing should be able to participate in and enjoy the benefits of the district’s services, programs, and activities” (DOJ-DOE p14)1. ● These requirements apply to all school-related communications, and when a public school is deciding what types of auxiliary aids and services are necessary to ensure effective communication, it must give “primary consideration” to the particular auxiliary aid or service requested by the person with the disability. (DOJ-DOE p27). IDEA (2004) “Special Factors” regulations specify that schools must provide the following supports for students who are deaf or hard of hearing [34 C.F.R. §300.324(a)(2)(iv)]: ● Opportunities for direct communication with peers in the student’s language and communication mode. ● Opportunities for direct communication with professional personnel in the student’s language and communication mode. ● Opportunities for direct instruction in student’s language and communication mode. IDEA (2004) also requires: ● Routine checking of hearing aids and external components of surgically implanted medical devices to ensure they are functioning properly [34 C.F.R. §300.113(a)(b)(1)] ● Audiology Services [34 C.F.R.§300.34(c)(1)] ● SLP Services [34 C.F.R.§300.34(c)(1)] ● Assistive Technology Devices and Services [34 C.F.R.§300.34(c)(15)] ● Highly Qualified Special Education Teachers [34 C.F.R.§300.18] To assist schools in meeting the language and communication requirements above, the following checklist describes supports to be considered for each student who is deaf or hard of hearing and those with other auditory learning needs. This checklist was developed and field-tested with input from all three professional groups via focus group meetings and online surveys. Categories are described as “student assurances” with activities and expected outcomes that should be addressed by the student’s team of educational professionals, including educational audiologists (Ed. Aud), speech-language pathologists (SLP), and teachers of the deaf and hard of hearing (TODHH). Because student needs change over time, this checklist should be completed at least annually. 1. U.S. Department of Justice & U.S. Department of Education (2014, Nov 12). Frequently Asked Questions on Effective Communication for Students with Hearing, Vision, or Speech Disabilities in Public Elementary and Secondary Schools. http://www2.ed.gov/about/offices/list/ocr/docs/dcl-faqs-effective-communication-201411.pdf

Copyright © 2018, Educational Audiology Association

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When the student’s team is designating primary responsibility for each activity listed, the professional scopes of practice and state licensure/certification requirements, as well as training and experience, should guide considerations for specifying responsible personnel. Areas with direct scope of practice implications are checked.

Student Assurances: Audiological and Equipment Needs 1. Audiological evaluations that include recommendations to enhance communication access and learning.

2. Diagnosis of auditory processing disorders (APD) with recommendations to manage

APD issues provided to school personnel for the classroom and to parents for out of school consideration.

Ed Aud

TODHH

SLP

Other

TODHH

SLP

Other

 

3. Management of auditory access in all educational environments 4. Assessment of classroom acoustics with recommendations made to improve classroom listening environments where necessary.

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5. Evaluation and fitting for personal hearing instruments, classroom, and other hearing assistive technology.



6. Management of hearing assistive devices including maintenance and troubleshooting.

7. Provision of training for school personnel and students, when appropriate, to

perform listening checks and basic troubleshooting to maintain proper functioning of personal hearing instruments and hearing assistance technology.

8. Provision of hearing assistive technology services including educating students, teachers of the deaf/hard of hearing, and other school personnel regarding technology performance and expectations.

9. Use of daily listening checks to monitor functioning of hearing technology used by students.

10. Other:

Student Assurances: Communication - Speech, Language, Auditory, Visual Needs

Ed Aud

11. Evaluation of current speech production skills including articulation, fluency,



voice, and resonance, as appropriate for the student’s preferred language and communication mode.

12. Evaluation of current language skills in the student’s preferred language and communication mode, including: ●

Comprehension, expression, and language processing in oral written, graphic and manual modalities



Phonology, semantics, syntax, morphology and pragmatics/social aspects of communication



Pre-literacy and language-based literacy skills, including phonological awareness



Description and interpretation of specific language communication skills and needs identified through appropriate formal and informal, standardized and non-standardized assessments.

13. Evaluation of communication-related visual and/or auditory skills and needs as appropriate in the student’s preferred language and communication mode.

Student Assurances: Communication - Speech, Language, Auditory, Visual Needs

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TODHH

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Roles and Responsibilities of Educational Audiologists

14. Implementation of an appropriate therapy plan to develop speech, language,

pragmatics, speechreading and auditory skills including strategies for generalization in the general education classroom.

15. Self-advocacy instruction and support to enable students to advocate for their needs with peers, school personnel and other communication partners including: ● ● ●

Evaluation and inclusion of communication goals targeting identity, selfadvocacy and communication repair strategies Inclusion of language and communication goals related to classroom accommodations and modifications Orientation and /or instruction for peers, families, and school staff regarding communication development, the impact of hearing loss, and communication repair strategies.

16. Services that ensure opportunities for students to develop peer-to-peer social communication skills including:

● ●

Facilitated support groups for children who are deaf or hard of hearing or who have other auditory disorders. Goals for communication repair strategies that will facilitate communication with peers. Orientation to hearing peers that encourages social interactions and communication.

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17. Other: Ed Aud

Student Assurances: Academic Needs

TODHH

SLP

Other

SLP

Other

18. Evaluation of educational performance in accordance with the requirements of IDEA 330.304 (b) that includes: • • •

Use of a variety (no single measure) of assessment tools and strategies to gather functional, developmental and academic information. Use of reliable and valid tools administered in the child’s preferred language or other mode of communication to yield accurate information. Measures administered by trained and knowledgeable personnel, according to procedures by the producers of the assessment tools.

19. Assessment that distinguishes learning issues related to hearing status from those related to other cognitive, sensory or physical challenges.

20. Specialized academic instruction to include preview and review of academic material



to help optimize learning.

21. Specialized instruction including expanded core curricular areas such as

communication, career education, self-determination and advocacy, social-emotional skills, technology and family education.

Ed Aud

Student Assurances: Academic Needs

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22. Assessment of literacy skills conducted in the child’s preferred language and communication mode.

23. Literacy development plans designed and implemented according to the individual student’s needs.

24. Provision of interpreting, notetaking, captioning, transliteration, and/or voice-to-text services to optimize access to instruction for those who require these supports.

25. Provision of optimal visual and auditory access for both assessment and instruction. 26. Other:

Collaboration Program Management Needs for Students who are Deaf/Hard of Hearing: Identify Individual Responsible for Coordination

Ed Aud

TODHH

SLP

Other

Chapter 2

27. Educational plans developed, reviewed, and implemented in a timely manner by

team members who have knowledge, skills, and resources related to the impact of hearing loss/deafness on communication, access to classroom instruction and academic performance.

28. Communication that is consistent between school-based instructional staff and other specialized personnel (e.g., private SLPs, interpreters, audiologists).

29. IEP and 504 development and meeting participation by one or more specialists in

hearing loss/deafness to address student communication, education, access needs and to develop a transition plan for post-secondary education/training/employment.

30. Education of students and their families regarding hearing status, communication approaches, associated accommodations, technology options, and self-advocacy.

31. Observation of classroom and school environments that continuously evaluates

and monitors communication access, classroom acoustics, and how children are functioning in these settings.

32. Consultation activities that ensure school personnel understand the language,

communication, social, and educational effects of hearing loss/deafness, technology options and associated accommodations.

33. Education of students and their families about resources in the community,

financial resources (for personal hearing technology), educational resources and opportunities to connect with other students who are deaf and hard of hearing and their families.

34. Other:

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APPENDIX

2–B Part C Roles of Audiologists in Early Hearing Detection and Intervention*

■■ ■■ ■■ ■■ ■■ ■■

■■ ■■

Attend equipment trainings and provide screening in-services to other personnel involved with the EHDI process. Assist with state data tracking and management through the screening, referral, and diagnostic process. Review the screening program outcomes to ensure that the protocol used has met the desired identification targets. Provide screening rechecks prior to referral for diagnostic evaluation. Assist with tracking referrals from screening to rescreening to assessment. Provide information to families about the screening/rescreening process and necessary follow-up steps for assessment, where appropriate. Participate as a resource for the community. Refer to the Part C point of entry within 2 days of rescreen to initiate the referral process for possible service coordination and Individual Family Service Plan (IFSP) services. Note: In some communities, this step may not be completed until a hearing impairment is diagnosed. However, if the family needs support and assistance to obtain a hearing evaluation, the Part C referral should be initiated.

Chapter 2

Role 1. Identification of children with auditory impairments using at-risk criteria and appropriate audiological screening techniques.

Role 2. Determination of the range, nature, and degree of hearing loss and communication functions by use of audiological evaluation procedures. ■■

■■ ■■

Assist families with referrals for initial diagnostic evaluation, helping them locate appropriate pediatric audiological testing facilities. Refer to confirm diagnosis if necessary. Assist in the IFSP process with the family and appropriate infant and toddler service provider.

Role 3. Referral for medical and other services necessary for the habilitation or rehabilitation of an infant or toddler with a disability who has an auditory impairment. ■■ ■■ ■■ ■■

Assist families in understanding diagnostic information (e.g., medical, genetics). Assist families in identifying appropriate medical and other services that may be needed. Provide impartial information to families about communication and intervention opportunities and educational services. Act as a liaison between medical providers, the family, and other IFSP team members.

Role 4. Provision of auditory training, aural rehabilitation, speech reading and listening device orientation and training, and other services. ■■ ■■ ■■ ■■

Participate as a member of the multidisciplinary IFSP team to plan services. Assist the IFSP team in developing functional outcomes around the priorities the family has identified. Provide parents with information about service agency options. Assist family in transition from Part C to Part B (school) services.

Role 5. Provision of services for prevention of hearing loss. ■■ ■■

■■

Provide hearing screening services through local Part C and Part B (Child Find) agencies. Conduct ongoing surveillance measures to monitor hearing of children “at-risk” for late-onset or progressive hearing impairment. Provide information regarding purpose of genetic counseling.

*Roles and responsibilities may be collaborative in nature, depending on availability of pediatric and/or educational audiology personnel and services in local communities. 51

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Chapter 2

Role 6. Determination of the child’s need for individual amplification, including selecting, fitting, and dispensing appropriate listening and vibrotactile devices and evaluating the effectiveness of those devices. ■■ ■■ ■■

Refer for personal and assistive hearing instrument selection and fitting. Assist families in identifying financial resources for amplification devices, when needed Provide ongoing monitoring of child’s auditory skills and review of recommendations to ensure technology is appropriate for the child’s current needs. Recommendations may change depending on a child’s performance and listening demands.

Note. From EAA (2002) and EHDI e-book (2019).

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APPENDIX

2–C Educational Audiology Scope of Practice

(Approved by the Board of Directors of the Educational Audiology Association August 6, 2019) Purpose

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The purpose of the EAA Scope of Practice statement is to identify and describe areas that are unique to the practice of audiology in education settings. Accordingly, this statement should inform educational licensure requirements for school-based audiologists, local school district educational audiology practice (NASDSE, 2018) as well as Au.D. and post-graduate professional development coursework in educational audiology. This statement expands on the audiology scope of practice statements of the American Speech-Language-Hearing Association (ASHA, 2018) and the American Academy of Audiology (AAA, 2004). Rationale Educational audiology has continued to evolve from early definitions, providing greater clarity and definition to the scope of practice for audiologists providing services to students in educational settings. A primary goal is to ensure that all deaf and hard of hearing students, regardless of eligibility status, have full access to communication, specifically, auditory information, in their learning environments. To do so requires that children are identified, appropriately assessed, receive counseling and other support services to address their hearing status and educational needs, provided with appropriate hearing assistive technology and assistive technology services, and that their personal and assistive hearing technology is monitored regularly to ensure that it is functioning properly. Background The specialized practice of audiology in education settings was first described in the 1965 Joint Committee Report, “Audiology and Education of the Deaf” (Ventry, 1965). The role of audiologists in educational programs and the qualifications and competencies needed to provide audiological services to children in educational settings were the two major areas of discussion of this committee. Key roles of audiologists included: • • • • • • • •

Complete audiological evaluation of children related to their admission to the educational program Annual assessment of children’s hearing, including an interpretation of the result to the teacher Hearing aid selection, orientation, and maintenance Application of knowledge about speech perception and speech pathology to the speech problems of deaf children Inservice training to help keep teachers abreast of new techniques and new information Parent counseling Evaluation, application, and selection of the amplifying systems and equipment used in the school Liaison between the school and the college or university training program or community speech and hearing center

The recommendations of this report influenced the definition of audiology in the first federal education disability legislation, the 1975 Education for all Handicapped Children Act, PL 94-142, now known as the Individuals with Disabilities Education Act (IDEA, 2004). IDEA 2004 Definition of Audiology (34 CFR 300.34(b)) (i) Identification of children with hearing loss; (ii) Determination of the range, nature, and degree of hearing loss, including referral for medical or other professional attention for the habilitation of hearing; (iii) Provision of habilitation activities, such as language habilitation, auditory training, speechreading (lip-reading), hearing evaluation, and speech conservation; (iv) Creation and administration of programs for prevention of hearing loss; (v) Counseling and guidance of pupils, parents, and teachers regarding hearing loss; (vi) Determination of the child’s need for group and individual amplification, selecting and fitting an appropriate aid, and evaluating the effectiveness of amplification. Copyright © 2019, Educational Audiology Association

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Definition: Educational Audiologist Educational Audiologists deliver a full spectrum of hearing services to all children, particularly those in educational settings. Audiologists are trained to diagnose, manage and treat hearing and balance problems. Educational audiologists are members of the school multidisciplinary team who facilitate listening, learning and communication access via specialized assessments; monitor personal hearing instruments; recommend, fit and manage hearing assistance technology; provide and recommend support services and resources; and advocate on behalf of the students. Educational audiologists provide evidence for needed services and technology, emphasize access skills and supports, counsel children to promote personal responsibility and self-advocacy, maintain student performance levels, collaborate with private sector audiologists, help student transitions and team with other school professions to work most effectively to facilitate student learning (www.edaud.org). School-Based Educational Audiologists refers to educational audiologists who provide services to students as school employees or via contracted onsite services. The Population Served by Educational Audiologists

Chapter 2

Students with all levels and types of auditory impairments including auditory neuropathy, unilateral or fluctuating hearing levels, or an auditory processing deficit, require the expertise of an educational audiologist. In addition, students with learning disabilities, reading/literacy difficulties, attention problems, and those struggling with English as a second language may benefit from the educational audiologist’s knowledge of how listening and learning are impacted by noise and classroom acoustics. Educational audiologists should support these students whether they receive special education and related services under IDEA or services through Section 504 of the Rehabilitation Act (1973). Scope of Practice The work of school-based educational audiologists may vary from one educational setting to another. However, professional practices must address the areas identified within IDEA under audiology: screening, assessment, amplification, habilitation, counseling, and prevention (34CFR300.34(c)(1); assistive technology and assistive technology services (34CFR300.5-.6 & C); and routine checking of amplification devices and external components of surgically implanted medical devices worn by children in school (34CFR300.113), Based on professional scopes of practice in audiology (AAA, 2004; ASHA, 2018), speech-language pathology (ASHA, 2007), and deaf education (CEC, 2018), the audiologist is the only professional that is qualified to fit and verify hearing aids and personal hearing assistance technology. Through collaborative partnerships, educational and clinical audiologists work together to promote the most appropriate hearing technology and support services for each child or youth they serve. Providing ongoing consultation to the school nurse on screening programs, the speech language pathologist for communication strategies, or a classroom teacher regarding acquisition of the phonemic information critical to literacy -- are all part of the scope of practice of the educational audiologist. Specific Roles of the Educational Audiologist include: Identification • Coordinating hearing screening programs for preschool and school-aged students ensuring professional standards and state guidelines are followed and screening personnel are appropriately trained. • Providing and/or managing hearing screening component of school-based Child Find programs. • Providing community leadership and collaborating with community agencies to increase awareness of hearing differences and to assure that all children and youth with reduced hearing loss are promptly identified, evaluated, and provided with resources and appropriate intervention services.

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Assessment • Performing and interpreting comprehensive educationally relevant evaluations, including functional measures, of peripheral and central auditory systems. • Making appropriate medical, educational, and community referrals. • Assessing students’ functional ability to access auditory information in the classroom to link diagnostic information, educational accommodations, and program planning. • Collecting and interpreting learning environment data from classroom observations, classroom acoustics measurements, and other assessments to determine the impact of auditory deficits on communication access, school performance, and social relationships. • Describing the effects of students’ hearing levels and auditory processing deficits on communication, academic performance and psycho-social development and making recommendations to address these problems to the student, parents, and school personnel as appropriate.

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• Managing the use and calibration of audiometric equipment. Amplification • Evaluating and making recommendations for the use of personal hearing instruments (e.g., hearing aids, cochlear implants, bone conduction devices). • Ensuring the proper functioning of all personal hearing instruments. • Evaluating, fitting, and managing personal and classroom remote microphone and other hearing assistive technologies to ensure access to auditory information using recommended verification and validation protocols. • Making recommendations for appropriate use and connectivity of personal and assistive technologies (radio, television, telephone, messaging, alerting, and convenience) for students. • Providing training and support regarding hearing assistance technologies to students and school personnel on use, care, limitations, and specific troubleshooting techniques. Habilitation • Facilitating and/or providing intervention to develop and enhance speechreading, auditory and listening, and communication abilities. • Facilitating and/or providing support for wellness and-social development including educating students about their hearing status, associated communication implications and accommodations, understanding current hearing aid and cochlear implant technology and how they best interface with hearing assistance technologies. • Providing training about hearing, hearing differences and other auditory disorders for school personnel to facilitate a better understanding of the impact of auditory impairments on language, learning, literacy and social development. • Facilitating opportunities for connecting with peers and adults who are deaf or hard of hearing. • Contributing to program placement decisions and making specific recommendations to address listening and communication needs. • Collaborating with school, parents, teachers, support personnel, and relevant community agencies and professionals to ensure delivery of appropriate services.

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Counseling • Providing training and support to parents/families regarding hearing differences and implications for language development, communication access, educational achievement, wellness and other areas to facilitate a better understanding of the impact of auditory impairments on language development, communication access, learning, literacy and social development. • Providing counseling to students to promote identity, self-determination, personal responsibility, self-advocacy, and social awareness. Prevention • Educating students and school personnel about the prevention of hearing loss. • Managing school programs for hearing loss prevention education. Contributions to the Multidisciplinary Team

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As part of the educational team, educational audiologists interact directly with parents, as well as general education teachers, teachers of the deaf/hard of hearing, nurses, and specialized instructional support personnel (e.g., speech-language pathologists, LSL specialists, educational interpreters, psychologists, social workers). The efforts of educational audiologists to improve access to auditory information in learning environments address a fundamental need for all students to be able to hear, and understand, with or without visual supports, in the classroom. This expertise is unique from that of other professionals whose focus is from an academic, social-emotional and/or speech language perspective. Together, the educational audiologist and other professionals comprise a team prepared to effectively address the needs of students with hearing, listening, and auditory processing difficulties. References American Academy of Audiology (2004). Audiology: Scope of Practice. Available from www.audiology.org American Speech Language Hearing Association (2018). Scope of Practice in Audiology. Available from www.asha.org American Speech-Language-Hearing Association. (2007). Scope of Practice in Speech-Language Pathology Available from www.asha.org/policy Council of Exceptional Children (2018). Specialty Set: Deaf and Hard of Hearing. Entry and advanced level of knowledge and skills for teachers of students who are deaf or hard of hearing. Revalidated 2018. Available from https://www.cec.sped.org/~/media/ Files/Standards/CEC%20Initial%20and%20Advanced%20Specialty%20Sets/Initial%20Specialty%20Set%20%20DHH%20%20 Revalidated%202018.pdf Federal Register (2006). Regulations for the Individuals with Disabilities Education Act of 2004. National Association of State Directors of Special Education (NASDSE), 2018. Optimizing Outcomes for Students who are Deaf or Hard of Hearing: Educational Service Guidelines, pp 69-71, Alexandria, Virginia: NASDSE. Rehabilitation Act of 1973, Section 504, 29, U.S.C. 794: US Statutes at Large, 87,335-394 (1973). Ventry, I. (Ed.). (1965). Audiology and Education of the Deaf. Washington DC: Joint Committee on Audiology and Education of the Deaf.

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CHAPTER

3

Partnering With Families With Janet DesGeorges

CONTENTS

Chapter 3

Positive Attitudes Rapport ■ Respect ■ Trust Effective Communication Informational Guidance Quantity of Information ■ Types of Information ■ Parent-to-Parent Communication Parent Involvement Committee/Task Force Work ■ Classroom Support ■ Parent Activities

“My tooth fairy.”

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CONTENTS 

(Continued)

Difficult Situations Parent/School Disagreement Over Individualized Education Program Services ■ Request for a Specific Brand of Amplification ■ Influence of Private Provider on School Services ■ Families That Have Difficulty Being Involved ■ Differing Opinions on Communication Modality Summary Suggested Readings Appendices 3–A Resources for Parents of Children Who Are Deaf or Hard of Hearing (Text/Online) 3–B Family Needs Interview for Families of Children Who Are Deaf or Hard of Hearing (Text/Online) 3–C  Childhood Hearing Loss Question Prompt List (QPL) for Parents (Text/Online)

Chapter 3

KEY  TERMS Parent involvement, family, rapport, bias, trust, respect, effective communication

KEY POINTS ■■

■■

■■

■■

■■

Parents are critical partners in the education of deaf and hard of hearing children. Parents increasingly have become their child’s primary advocate in schools. The concept of partnership should not be viewed as an additional burden from the professional viewpoint, but as a positive and critical component to meeting the goals of ensuring student success. Families encounter all kinds of emotions throughout the different phases and time periods of raising a child who is deaf or hard of hearing. There should not be an assumption that families move through their emotions in a linear manner—that is, grief in the beginning, and then “moving on.”

The education of students who are deaf or hard of hearing is complex. It requires the participation, expertise, and input from the professionals who are serving these students, in conjunction with a partnership with families. Research conducted over the past 30 years identifies parent involvement as one of the most important factors in student success in school (Epstein, 2001; Henderson & Berla, 1994; Luckner & Muir, 2001). Benefits of engaging families include higher reading scores, higher grades on homework, improved attitudes toward school, and improved relationships between parents and teachers (Donahoo, 2001).

Balancing the desires of parents and the opinions of professionals for shared decision-making can be one of the most difficult educational challenges. As parents have acquired greater knowledge and involvement in their children’s educations, they have necessitated change toward better accountability and “individualization” to obtain services that address the needs of their children. Part C of the Individuals With Disabilities Education Act (IDEA), along with the early hearing detection and intervention (EHDI) system for families of children who are deaf or hard of hearing, have heightened our awareness of the needs and roles of families. The shift from being the specialist to becoming a multi- and interdisciplinary team member has not always been easy for audiologists or other professionals. Yet the power and impact of collaboration by a team of specialists that includes parents as equal partners cannot be overestimated. A relationship based on partnership and empowerment where the understanding is “together we can” can go much farther than a “we-they” arrangement to foster successful outcomes from the educational process. This chapter’s discussion is primarily about the educational audiologist’s role in supporting parents, providing them with information, and helping them make decisions. Partnering to address these goals can bring a greater level of success. Although these activities may be considered part of the counseling process, we should be careful how counseling activities are defined. Providing information and support to parents as they make decisions about methodology and programs is more guidance than counseling. Specific counseling services are usually directed toward helping parents work through the grieving process or helping their children with personal concerns or challenges associated with their hearing status (see Chapter 10, Supporting Wellness and SocialEmotional Competence, for more information on counseling students). Whether preventive or prescriptive, professional

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counseling should be left to individuals who are appropriately trained and who have specific experience working with individuals who are deaf and hard of hearing. When situations arise that require professional counseling, and they often do, refer the child and family to the appropriate school counselor or psychologist. If an appropriately trained counselor or psychologist is not available, work with the school to identify and contract with one. The value of understanding the implications associated with various hearing levels and deafness and direct communication with the student cannot be minimized. The following questions emphasize the context crucial to establishing and maintaining positive and supportive relationships with parents that are addressed in this chapter: ■■

■■

■■ ■■

■■

How can positive attitudes be developed and maintained with families? How can effective communication be established with families? How should information be provided to families? What can parents do to become more involved in school activities and to support the specific needs of children and youth who are deaf and hard of hearing? When difficult situations arise, what strategies can be used to facilitate positive outcomes?

POSITIVE  ATTITUDES Effective relationships with parents begin with healthy attitudes. The attitudes that people develop are, for the most part, shaped by experience, personality, and self-awareness. Some people have more pessimistic viewpoints, tending to expect the worst from a situation, while others have outlooks that are more hopeful. Educational audiologists work with a variety of people from a wide range of backgrounds and cultures. In public education, where there is no option of choosing whether or not to provide services for children and their families, the attitudes of some parents can be very challenging, while others are rewarding. Establishing effective relationships with parents requires a reciprocal understanding where both parties share respect and trust to sustain their partnership. Rapport, respect, and trust are considered briefly in the following sections as important steps toward building effective relationships with families. The integration of these skills can have a positive influence on the attitudes of the individuals involved.

Rapport Establishing rapport with a family is the first step toward building a healthy relationship. Increasing our sensitivity to how each family functions, their resources and motivations, interaction, and learning styles is helpful. Understanding each family’s dynamics can foster interaction techniques that are more likely to be compatible with that family’s style. While maintaining a professional atmosphere, it is possible

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to be relaxed with some families, formal with others, frank with some, and gentle with others. Avoid perceptions of intimidation or superiority, as these are counterproductive to building a healthy relationship. One effective approach for developing rapport is called “joining the family” (Haley, 1976). Haley suggested that interventionists become part of the family system to achieve more effective services for young children by being a more integral part of the support structure. Although home service is not a routine activity for many educational audiologists, there are several advantages to “house calls.” A visit to the home to meet the family members can not only help to establish a relationship but will also provide the audiologist with valuable insights and information to facilitate the diagnostic, habilitation, and educational process. A home visit provides an opportunity to observe the family setting and interact on “their turf,” which is often more comfortable for caregivers. A visit to the home can also provide additional insights into the home environment and culture, routine communication styles and structure, functional use of hearing, discipline, daily routines, extended family members, and available toys, books, and other materials. If such a visit is not possible, the educational audiologist is encouraged to collaborate closely with any home interventionists that have been or are currently involved with families. Empathy is another important component in building a relationship. Individuals can be empathetic without having had identical personal experiences. The development of reflective listening skills, learning what questions to ask, how and when to ask them, and how to interact in a nondirective and nonjudgmental manner are all critical aspects of empathy that are discussed further in this chapter. Genuine care and commitment to assisting the family are essential. The ability to put oneself in the family’s situation and to look outward from their perspective often provides a more realistic sensitivity to the family’s concerns and needs and can result in a stronger partnership with the family. Empathy can also be built by reading articles from parents about their experiences raising a child who is deaf or hard of hearing. This background can lead to a broader and more diverse understanding of the uniqueness of families. One such resource is the Hands & Voices blog (http://handsandvoices .org/deafhardofhearingchildren/).

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Partnering With Families

Respect To continue to develop a productive relationship, all parties should respect one another. Respect does not mean agreement. Rather, it describes how people are treated and the honor they hold for one another’s beliefs. Recognition of the importance of the parents and family in the diagnostic and habilitation phases is essential. Educational audiologists, regardless of their own personal biases or beliefs about what is best for an individual child, must strive to maintain an open attitude and acceptance of the options a family may choose. Respect for the family’s time, their need and desire

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to understand all information clearly, including the educational audiology services and intervention program, and their need to make decisions for their child’s current and future needs reinforces their role as the primary caregiver and case manager in the long-term process. Likewise, the parents and family should also be respectful of the audiologist’s time, efforts, and commitment to providing services for children and youth. Another component of respect is sensitivity to socioeconomic factors, family constellation, and cultural differences, as well as acceptance of the unique characteristics that may be associated with a variety of family cultures and systems. Services need to be responsive to family values and beliefs. If an educational audiologist feels uncomfortable with certain cultural issues or environments, relationships and effective outcomes may be compromised. If such discomforts exist, it is advisable for educational audiologists to acknowledge their feelings and discuss alternative options or modifications for service delivery with their supervisor without compromising their professional ethics. Alternative options should include deliberately seeking further education, resources, and opportunities to build skills in the area(s) of discomfort. Finally, respect requires extra care and attention to confidentiality. The world of hearing challenges/deafness can be surprisingly small, and families who are concerned with guarding their privacy should be supported in their efforts. Families should be made aware that all school employees, including educational audiologists, must abide by regulations under the Family Educational Rights and Privacy Act (FERPA), as well as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) when applicable, as these laws prohibit disclosure of personally identifiable information for students and their families without family knowledge and consent (see Appendix 1-C for more information on FERPA and HIPAA).

Trust Once rapport and respect have been established, trust should be inherent. Positive interactions over time continue to strengthen good relationships. Credibility is a critical feature of trust. Professional competence must be demonstrated before trust with the educational audiologist can be established. The audiologist’s expertise should be apparent in the technical aspects of diagnostics and habilitation, communication skills, collaboration with other agencies, and followthrough. Educational audiologists who return calls promptly and are careful to only make commitments that they can fulfill will earn trust more quickly from the families they serve. Trusted professionals recognize when referrals to other individuals should be made for services that are either outside the purview of educational audiology or beyond the audiologist’s expertise. Just as educational audiologists specialize in assessment and intervention within educational

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environments, other audiologists may have more expertise in the fitting and programming of implantable hearing technology. Trust in a relationship evolves and, therefore, is strengthened over time as interactions between the parties continue to reinforce the initial foundation on which it was begun. Patience and sensitivity by all parties of a collaborative relationship result in increased trust over the long term. A reflection of trust is the ability for parents and professionals to be authentic and honest with one another, even when there is disagreement, knowing that sharing sometimes difficult conversations will not affect the relationship.

EFFECTIVE COMMUNICATION Parents deserve open, honest communication. This means that professionals must take time to listen and acknowledge what parents say. Furthermore, professionals should set aside their biases to work as a member of a team for the best interests of the child/youth and his or her family. Effective communication practices, as shown in Table 3–1, are especially pertinent during the multidisciplinary assessment and collaborative planning processes because of the numbers of people and services involved (see Chapter 13 regarding effective communication practices with school teams). Effective communication with families is not always easy. Although some parents seem to have little motivation or understanding of the real consequences of reduced hearing, despite our efforts, it can be encouraging to remember that most families will develop skills over time when given support, information, and modeling. Remember that your efforts may lead to further success in the future, even if you do not see results. It is important not to give up. For others, language and cultural barriers distance families from participating in the school environment. When communicating with families from diverse cultures, educational audiologists need to be sensitive to the impact of differing communication styles (e.g., eye contact, the use of space), the role of gender within various cultures, potential differences in value systems, and the use of sign language or foreign language interpreters who can also misunderstand and, in turn, miscommunicate unfamiliar information (Alberg, 2003). The transition from familyfocused early intervention to school-based education can be a difficult adjustment for parents. In addition to understanding the family’s perspective, professionals also must check their internal barriers, such as those described in the text box. The extra time and effort invested, however, can result in more productive and stronger partnerships over time. Some strategies for communicating with families include the following: ■■

■■

Set aside personal biases and assumptions regarding the family’s wishes for their child. Listen first and listen with commitment; effective listening requires concentration on what the person is saying

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Partnering With Families TABLE 3–1  Effective Communication Skills ■■ ■■ ■■ ■■ ■■ ■■

Paraphrasing

■■ ■■ ■■ ■■ ■■

Powerful Questions

■■ ■■ ■■ ■■ ■■ ■■ ■■

Reflective Feedback

Gain clarity about an issue; Understand the needs, perceptions, and emotions of the speaker; Gather data for feedback; Allow the speaker to refine thinking by speaking to an attentive listener; Seek patterns of behavior; and Lay a path for building responses and solutions. (p. 3) Fully attend Listening with the intent to understand Capture the essence of the message in a paraphrase that is shorter than the original statement Reflect the essence of voice tone and gestures Paraphrase before asking a question: Pause, Paraphrase, Probe Reflect active and powerful listening and understanding of each person’s perspective Presume positive intent Evoke discovery, insight, commitment, or action on behalf of the person Challenge current assumptions of the individual Create greater clarity, possibility, or new learning Move the individual or team toward what he or she desires Move the thinking forward to current and future actions and do not focus on having the person justify or look backward

Reflective feedback clarifies ideas or actions under consideration and offers concerns, values, and suggestions: ■■ Clarify questions or statements for better understanding ■■ Value statements communicate positive features of actions and move toward preserving and building upon them ■■ Reflective questions communicate concerns, considerations, or options toward improvement Statements should: ■■ Consider the content of the message and the potential impact on the relationship; ■■ Say what needs to be said (the content) in a way that supports another’s growth and maintains a positive relationship.

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Committed Listening

Note. From Kee, Anderson, Dearing, Harris, & Shuster (2010).

Barriers to Committed Listening Internal Distractions ■■ Emotions and thoughts that have the potential to hijack our attention Physical Barriers ■■ Fatigue, hunger Emotional Reactions ■■ Reactive listening, the speaker uses words that triggers our “hot button” Biases and Judgments ■■ Previous experiences with the speaker often influence our ability to listen with intention

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Bias around poverty, race, religion, and lifestyle may interfere with listening fully to a person’s point of view, especially when we confront our own values ■■ Semantic misunderstandings for words that carry different meanings and may be filtered through our personal experiences, beliefs, education, and mindset External Distractions ■■ Cell phone rings or vibrates during conversation ■■

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and conveying. It shows the person that you care and want to fully understand his or her perspective. Begin by asking the parents about their concerns and their observations of their child. Completing a history form with the parents is a good opportunity to obtain this information. The Family Needs Interview in Appen­ dix  3–B is another effective tool to open the door to conversations about sensitive topics. Include parents in the assessment of their child, and describe each step of the evaluation process. Their participation will help them understand the results. Spend extra time and effort to have parents leave with at least a basic understanding of the outcome of the evaluation. Acknowledge when information or answers to questions are not known or when additional information would be helpful. Let parents know when they can expect follow-up on information requested. Provide parents with written information to review and share with other family members, as well as other professionals. Provide parents with a report (use accurate but simple language) that includes a description of the implications of the hearing status and current recommendations. Obtain written parent permission to share information and to copy the report to appropriate school, private practice, medical, and other professionals. Conduct follow-up phone calls to inquire how the child is doing and to see if the family has additional questions. These calls are indicative of the educational audiologist’s care and concern; the unsolicited contact goes a long way toward building and sustaining an effective relationship. Remember to use strategies for developing rapport, respect, and trust in all communications.

INFORMATIONAL GUIDANCE Educational audiologists practice in the schools to provide service to and support for children in their learning environ­ ments. With children and youth who are deaf or hard of hearing, the educational audiologist’s primary role is to help identify and advocate for student needs related to listening and communication access and learning. However, consistent and strong parent support often affects the way a student performs more than the work of the educational audiologist and other school team members. Even better results can be achieved when the parents and the school are working together for the same outcomes. A major step in developing effective relationships and shared decision-making is to provide families with information. Trained parents and active parent organizations such as Hands and Voices, Inc. (http:// www.handsandvoices.org) can be a valuable resource for parents and caregivers. The power of parent-to-parent communication cannot be overestimated. Information is powerful; it can enable and empower parents to make choices

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for their child and family. The following strategies can help audiologists facilitate parent empowerment: ■■

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foster skills to develop independence and a sense of competence and worth in families; move from professionally directed services to familycentered/team-directed services; help families to see themselves as integral to achieving solutions to problems; develop a relationship where families perceive audiologists as having helpful knowledge and skills; create a problem-solving partnership between you and the family; understand that families often use both intuition/gut feelings and objective data to make decisions and to advocate for their child, and professionals can support parents by respecting their right to process decisionmaking both subjectively and objectively; and capitalize on trained parents of deaf and hard of hearing organizations to provide information.

To be effective, information must be presented in a manner that parents and family members can easily understand and that can be individualized for each family, child, and situation. When information is used incorrectly, it can lead parents down a path of stress and potential problems. Many families and caregivers need multiple opportunities to hear and discuss information, especially when it addresses a topic that is new for them. Educational audiologists must recognize that information might not be processed or retained as it was intended. Phonak organized a group of pediatric audiologists and parent representatives (English et al., 2017) to develop a list of questions for parents to use as prompts with their audiologist or early intervention provider in the areas of diagnosis, family concerns, management of devices, and support systems. The Question Prompt List (QPL) is located in Appendix 3–C.

Approximately half of new information is forgotten immediately, and half of unfamiliar information is remembered incorrectly.

Nuggets from the Field There must be ample, and often repeated, discussion time with the educational audiologist to provide clarification of information, to respond to questions, and to provide objective guidance.

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It can be difficult to decide how much information parents should be provided with and under what time frame. Each parent has a different capacity to absorb various quantities of materials. The degree of information necessary is usually a function of where a family is in the diagnostic or treatment phase of intervention. Typically, the parent of a newly diagnosed infant or child will require a great deal more general information than the family of a child diagnosed 5 years previously, although as the educational situation changes and technology options increase, all parents will need updated information. In the early stages after identification, we believe it is best to give parents enough information to introduce the basic areas they will need to be aware of during their child’s early development and education. Some professionals may feel this amount of information is too much for parents to process, but this strategy allows the family to decide how much they want to read, review, or access on their own timetable. It also gives parents adequate information in the event they move or are not seen again by an audiologist for some time. Additional information can also be given at each appointment, if there are sufficient opportunities for discussion with the audiologist. When providing large packets of information to parents, always identify the materials that require their immediate review. Noting or highlighting the materials that are especially pertinent to their child’s situation is also helpful. Further reading can be suggested for follow-up visits. Some parents respond to these “assignments” in a formal way; for others, a suggestion to read an article may be more appropriate. Generally, parents should determine when they are ready for more detailed information. Their questions are often indictors of when they are ready for more and the type of information they want. A good strategy for determining how much information a family is wanting is to directly ask them, “Do you want more information?,” “Are you feeling overwhelmed?,” “Can I help you with specific resources that you have questions about?” When families feel they are in a trusting relationship, they are more likely to open up and share their concerns and questions. Follow-up appointments are key opportunities for audiologists to support and guide parents.

and videos/CDs available for parents, sites for ordering materials, and information about national resources and programs. The types of information provided to families should be reflective of the child’s status—that is, current age, age of identification, type of hearing condition, hearing level, and whether the family has already been involved with an intervention program. Universal newborn screening follow-up programs often provide a packet of information to parents of infants with newly identified hearing loss. The educational audiologist should check to see if the family still has this information, and, if so, use it as a starting point. In addition, educational audiologists need to be prepared to counsel parents whose child’s hearing condition was identified later (i.e., after infancy), those who had a delayed onset, or those whose loss has progressed, and to develop a collaborative relationship with families who have been dealing with intermittent programming while attempting to confirm a diagnosis and obtain services for their child.

Information for Families: Phase I—Newly Identified or Recently Identified Though the world of deafness can seem intimidating and difficult to navigate, families often bring strength to the situation that forms the first step toward self-confidence and emotional availability to receive the new information they will need. These components include a mother’s and/or father’s love, seeing their child’s potential as a person, understanding the family’s priorities and values, and their ultimate right and responsibility for their child. Families are more self-confident when they sense that they have something to contribute. This confidence leads them to the knowledge that they are the experts of their own child. The most immediate and critical information to be provided to parents at this stage should target the following areas: ■■

■■ ■■

■■ ■■ ■■ ■■ ■■

Types of Information There are many types of information and formats that are effective with families and caregivers. Historically, information has been provided through print material and faceto-face discussion, but as personal computer, phone, and other technology use has increased, apps, social media, and web searches provide instant access to all sorts of information and advice. Additionally, online instruction programs provide access to sign language and other educational programs. Appendix 3–A contains a list of materials, books,

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Chapter 3

Quantity of Information

63

understanding the basic parameters of their child’s hearing condition (i.e., level, type, configuration); possible cause(s) of the hearing condition; implications of this hearing condition (e.g., audibility, language, communication, development); connections to intervention programs; role of audibility and visual access; amplification options; language and communication options; connections to other parents; and connections to deaf mentors, guides, and/or role models.

Whatever time is necessary must be taken to complete this phase of the adjustment process. Depending on the diagnostic situation, this responsibility could belong to the educational audiologist, to the dispensing audiologist, or, even better, both working together to support the family in home, early childhood, and school environments. We have found this collaboration to benefit all parties because it uses each audiologist’s time more efficiently, shares the responsibility, and demonstrates to parents that the audiologists work together

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for their child. As part of the information conveyed, parents need to learn about communication options, learn about the importance of audibility and amplification, and gain a realistic expectation of what each option might provide. Once the fitting process begins, a written home usage plan can be particularly helpful in supporting parents during the adjustment period. This program should include charts for recording wearing time and listening activities to do when the child is wearing hearing instruments. Information for families of children newly or recently diagnosed is usually more general but still should provide the breadth necessary to touch on most of the critical topics parents immediately face. One of the most helpful activities the audiologist can do is to compile a resource booklet for parents. Our experience with this type of information has been extremely positive. Audiologists (educational and private) within a community should meet to devise such a booklet and to develop a list of local resources if this is not already available. As mentioned previously, many state newborn hearing screening programs in conjunction with familybased organizations have developed such information booklets or packets as part of their early hearing detection and intervention (EHDI) systems, but community audiologists and service providers should add local information and resources for families. Production and duplication costs can be shared between the school district (often production) and the private providers (duplication of copies for their clients). By involving all area audiologists, an ownership in the product is attained, and audiologists are given the opportunity to improve communication among themselves as they share in the development and compilation of resources and materials. The following topics are suggested for the contents of a booklet: ■■

■■

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an introductory page: a description of the contents, the purpose, and how to use the manual; communication options: a definition and description of each communication option in a straightforward, nonbiased manner (see Appendix 9–J for an example); the effects of reduced hearing: a description of the implications of the varying levels of hearing, including a picture of an audiogram with common sounds and speech banana (see Appendices 5–B and 5–C for examples); amplification options: a basic description of the various personal and hearing assistive technologies; glossary: a listing of terminology and definitions common to audiology and deaf education; reading and resources list: a compilation of books, videos/CDs, national organizations and resources, and state organizations, resources, and providers; local resources: a listing (with contact information) of city, county, and regional resources; these may include …… general information regarding community services for children (IDEA Part C agency should be included here);

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financial resources (Supplemental Security Income [SSI], Medicaid, state disability services for children, service organizations, etc.); …… hearing and speech services (audiology and hearing aids, hearing therapy, speech therapy, hearing aid bank and loaner programs, if available, etc.); …… health/medical resources (county health depart­ ment; health and medical clinics that serve children; Early and Periodic Screening, Diagnostic, and Treatment [EPSDT] benefit [Medicaid]; Women, Infants, and Children [WIC]; ear, nose, and throat physicians; etc.); …… public schools: Child Find and specialized programs for deaf and hard of hearing children, Head Start, etc.; …… parent/family supports (parent groups and organizations for disabilities and deaf/hard of hearing children and their families, preschool support groups); …… deaf mentor/deaf and hard of hearing guides and role models; …… child care and respite services; …… transportation; …… housing (transition, homeless, abuse protection); …… counseling; and …… emergency (poison control, suicide hotline, firepolice-ambulance). ……

In Colorado, a group of professionals (audiologists, deaf educators, habilitation specialists, Deaf adults, and State Department of Health and Education representatives) and parents began by developing a booklet entitled, RESOURCES for Families of Children With Hearing Loss in Colorado. This booklet was funded and disseminated to every audiologist in the state through the Colorado Department of Education. Within each community, audiologists were instructed to develop a list of “local resources” that would be added to the main booklet, and then to reproduce and distribute copies for each local audiologist for dissemination to parents whenever hearing loss was diagnosed. This process attempts to ensure that all parents are provided the same basic information and options throughout the state. The Colorado chapter of Hands & Voices continues to maintain this resource booklet (http:// www.cde.state.co.us/cdesped/deaf.asp). Several other states now have their own resource information compiled in print, on a CD, and/or accessible through an online web address. Check with your state’s early intervention (IDEA Part C or EHDI) program for more specific state information. Parents should have information that addresses the specific type and level of hearing identified for their child. The audiologist (or groups of audiologists) may wish to develop packets of information that focus on common etiologies or diagnoses, such as otitis media, unilateral hearing loss, progressive and late-onset hearing loss, noise-related hearing loss, Usher syndrome, or auditory neuropathy/dyssynchrony spectrum disorder (ANSD). Information specific to genetics and hearing is also important.

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Information for Families: Phase II— Living With the Diagnosis Once a family has adjusted to the diagnosis of their child’s hearing condition, they should be ready for more detailed information about communication, programs, and education options for their child. The first phase of adjustment is often more internal, that is, understanding and meeting the immediate needs of the child and family. Factors that influence parents’ timelines for adapting to their child’s diagnosis are identified in Table 3–2. The second part of adjustment includes many external activities, such as meeting with other parents, meeting adults who are deaf or hard of hearing, and attending parent groups, workshops, or Deaf culture activities. The benefit of early childhood home intervention programs is that the parent education process is ongoing and can proceed at the family’s pace as they are ready to explore new areas. For preschool and older children in formal educational settings, services in the home typically are not available, often because of time and travel limitations for public school program staff. As a result, special efforts must be made to keep parents informed as well as connected to local

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TABLE 3–2  Factors That Influence Parents’ Adaptation to Hearing Loss ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

Marital situation Family size Birth order Temperament match Financial situation Flexibility for change Family acceptance Previous experience with disability/hearing loss

Note. Adapted from Clark and English (2004).

and state parent organizations. Information about workshops, parent groups, and sign language classes is important to families. Resources for additional otology or genetic consultation to evaluate the etiology of the hearing loss should also be provided for parents who do not have this information. This phase is also a good time to meet deaf or hard of hearing adults if this opportunity has not yet been provided. Their insight and experience can be helpful to parents and provide a perspective that hearing individuals cannot authentically represent. There are several books written by parents for parents and by adults who are deaf or hard of hearing that are included in Appen­ dix 3–A. Often a book or a video can serve as a starting point for ongoing discussions to help parents adjust to changing family dynamics that often follow diagnosis of reduced hearing. Families encounter all kinds of emotions throughout the different phases and time periods of raising a child who is deaf or hard of hearing. There should not be an assumption that families move through these emotions in a linear manner (i.e., grief in the beginning, and then “moving on” once the diagnosis has been made and intervention begun). Rather, different feelings can resurface each time certain milestones are reached that cause the impact of the hearing loss to be particularly apparent. The most difficult times are often transition periods such as entry into preschool, kindergarten, at puberty, at high school graduation, and independent living. A heightened sensitivity to these circumstances will help educational audiologists be prepared to offer parents support through counseling, meetings, or communication with other parents who have been through these difficult times, and parent support groups. The Ida Institute (https://idainstitute .com) program, Growing Up With Hearing Loss, is a counseling tool that helps parents of young children prepare for these important transitions, as well as the children themselves as they get older. This program is described in Appendix 10–F.

Chapter 3

The National Institute on Deafness and Other Communication Disorders (https://www.nidcd.nih.gov) and Boys Town National Research Hospital (https://www.boystownhospital .org) provide useful resources on genetics and etiologies of various hearing conditions for parents. Additional resources for these topics can be found in Appendix 3–A, and additional sites for information can be identified by searching relevant databases on the Internet. Parents can order materials from online and print catalogs that include products such as videos/CDs, books for parents on hearing conditions, and intervention programs and materials (Appen­dix 3–A). The Family Needs Interview mentioned previously (Appendix 3–B) can also be given to families periodically to determine areas where the family may desire more information or support. Parents also need information about their rights and the Individualized Family Service Plan (IFSP), Individualized Education Program (IEP) process, and Section 504 plan. This information should be provided in print as well as explained. Parents typically are involved with the IFSP process first since age of identification is generally younger than 3 years. Because there is so much flexibility in how IFSPs are conducted and written, and because the parent is more “in charge,” the IFSP can be a much less intimidating situation than the IEP (see Chapter 11, Developing Individual Plans, for more information on development of the IFSP and IEP and transition between them). Websites developed by parent organizations, such as Hands & Voices (http://www .handsandvoices.org), provide a wealth of information, written from a parent perspective. The Hands & Voices Advocacy, Support, and Training Program has specific resources for educational advocacy (http://www.handsandvoices.org /astra/index.html).

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Parent-to-Parent Communication Professionals can increase their effectiveness in providing information to families by partnering with state and local parent organizations. Jackson, Wegner, and Turnbull (2010)

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examined family members’ perceptions, preferences, and satisfaction with family support services. Based on the results of a questionnaire, it was found that families valued their discussion with other parents of children who are deaf or hard of hearing, identifying them as one of the top sources of support. Henderson, Johnson, and Moodie (2016) conducted a dual-stage scoping review of the literature that included 39 peer-reviewed articles on parent-to-parent support. Data from this literature were identified, extracted, and organized into libraries of thematic and descriptive content. This information was then used to create an eDelphi study with a handpicked group of 21 experts in parent-to-parent support from seven different countries. The findings from this dualstage scoping review and eDelphi study provide a conceptual framework that defines the vital contribution of parents in assisting other parents new to a diagnosis. The framework design includes 3 constructs (Well-Being, Knowledge, and Empowerment) and 17 components. These constructs and components are presented in a closed helix visual design with the supporting parent and learning parent on opposite curves. The helix represents the exchange of information between the parents (Figure 3–1). The parent-to-parent connection continues to grow as more state EHDI programs adopt the Guide By Your Side Program (GBYS) of Hands & Voices. This program connects trained parents of deaf and hard of hearing children with parents and family members of infants and toddlers with newly identified hearing conditions to promote selfefficiency and reduce isolation by exploring the common

“Successful family involvement is not a sporadic activity. It is a sustained commitment to instill the habits of learning and to set high expectations. It is making connections to teachers and schools not only when trouble arises, but as a part of the everyday process of children’s schooling.” Richard W. Riley, Secretary of Education, 1994

bond and shared experiences of families. Many GBYS programs serve families as their children move into the school years as well, particularly during periods of transition. Collaboration between professionals and parent leaders from a program such as GBYS can result in a complementary relationship that benefits the families and children being served as well as the professionals supporting those families.

PARENT INVOLVEMENT The concept of partnership should not be viewed as an additional burden from the professional viewpoint, but as a positive and critical component to meeting the goals of ensuring student success. From the very beginning, families can begin to learn the tools that will help them, including the laws, policies, and best practices to become equal partners in their

SYSTEM NAVIGATION & TRANSITIONS EDUCATION

SPECIALISTS, SERVICES RESOURCES, INFORMATION, SKILLS

ENT

ENGAGEMENT, DECISION MAKING, PARENTING, ADAPTATION, PROBLEM SOLVING

EMPOW ERM

COMPETENCE & CONFIDENCE

LEGAL RIGHTS, REPRESENTATION, FINANCIAL RESOURCES

LEARNING PARENT

ADVOCACY

WELL-BEIN G

RELATIONAL, EMOTIONAL

KNOWLEDGE

KNOWLEDGE

PARENT & FAMILY

SELF-DETERMINATION PARTICIPATION, GOALS

G

MENT EMPOWER

CHILD

IBU TIO N

IN WELL-BE

SUPPORTING PARENT

CONTR

FIGURE 3–1  Conceptual framework of parent-to-parent support for parents of deaf and hard of hearing children. (From Henderson, Johnson, & Moody, 2016.)

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Committee/Task Force Work All parents should be welcome participants in school programs. Whether it is in helping to plan workshops, working with curriculum development, planning and implementing parent programs, or considering hiring a new teacher or staff member, parents should be involved in the process. Not only is it often a challenge to include parents, but it can also be difficult to find a variety of parents who are willing to give of their time to participate actively on a committee or task force. Exercise caution when recruiting only one parent for an activity; avoid the “token” parent syndrome. Invite

multiple parents, and make their involvement meaningful so they feel like authentic members of the committee and process. When this type of parent participation occurs, the outcomes are stronger and have greater credibility. Furthermore, through this process, parents learn about school issues and increase their understanding of the challenges teachers and staff face. Table 3–3 suggests questions that parents can ask regarding their working relationships with professionals. Some parents participate because they have an agenda of their own that needs attention. Although they are not necessarily disruptive to the process, their focus is set narrowly on their own issues, rather than on what is best for the group. To avoid, or at least minimize, these actions, screening of parents who have volunteered or selecting an alternative representative may be necessary. In addition, a set of operating rules for the participants of the group is essential. The goal or purpose of the group needs to be stated clearly, with timelines and outcomes identified and agreed on. All members should be respected for the perspective they bring to the task but refocused when they stray too far from the objectives.

Classroom Support It can be very helpful to involve parents in day-to-day classroom activities. Parents are often eager to assist in class projects, tutoring, or being a classroom helper. While it can be difficult to steer a parent away from working with his or her own child (and it is usually necessary to do so), the instructional modeling that occurs by having the parent observe how the teacher delivers instruction and then the opportunity to practice with other children has carryover benefits when the parent is with the child outside of school. When parents have options regarding classroom placements, one area in which they may choose to advocate is in helping to identify the best classroom environment for their child, including teaching style and delivery of appropriate accommodations. The Placement and Readiness Checklists (PARC, Appendix 11–D on the companion website) contain a classroom observation checklist that parents can use when considering options for classrooms, teaching styles, and

Chapter 3

child’s education. Educational audiologists can support this process by standing with parents, helping them develop the skills to be effective participants in their child’s education. Schools can build the foundation for parent involvement from the beginning of the student’s school years by clearly communicating a desire for families to be engaged and valuing their contributions. Families who know they are critical to the educational life of their children beyond the IEP meeting see the reward of their efforts in the successful, self-advocates their own children can become. As noted in Beyond the IEP (http://www.cohandsandvoices.org/newsite /wp-content/uploads/2015/02/Beyondthe-IEPsept2010.pdf ), remind them of their right and responsibility to have a voice in their school and that they are always their child’s best advocate. They know about the implications of their children’s hearing status in a way that educators cannot know. Though there should be many people on the student’s team of advocates, remind families that they are needed to help connect the dots between education and deafness. Parents generally want to work with their children’s teachers and other professionals. In some situations, and particularly once their child enters formal schooling, they may feel they have less control and that they are not kept informed or given enough time to discuss their child’s progress. The parent questions in Table 3–3 may be helpful for parents when trying to determine what they need and want from their relationships with professionals.

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TABLE 3–3  Parent Checklist of Questions to Ask When Working With Professionals   Do I believe I am an equal partner with professionals and accept my share of the responsibility for solving problems and making plans on behalf of my child?   Do I clearly express my own needs and the needs of my family to professionals in an assertive manner?   Do I treat each professional as an individual and avoid letting past negative experiences or negative attitudes get in the way of establishing a good working relationship?   Do I communicate quickly with professionals serving my child when significant changes or notable events occur?   When I make a commitment to a professional for a plan of action, do I follow through and complete that commitment?   Do I maintain realistic expectations of professionals, myself, and my child? Note. From Focal Point, 2(2), 1988. Research and Training Center, Regional Research Institute for Human Service, Portland State University, Portland, Oregon 97207-0751.

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FIGURE 3–2  Parent involvement.

Chapter 3

services for their child. When teachers and school building administrators are feeling the pressure of time and energy constraints, parent involvement can often be seen as an extra “add-on.” Creating a powerful parent involvement force in a school may take some extra energy in the beginning but can ultimately be the very resource to help teachers in their day-to-day work (DesGeorges, 2010).

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Parent Activities One of our biggest challenges with families is keeping them active in parent groups. It often seems that it is the same parents who participate in school-sponsored events, and parents of younger children participate more frequently than parents of older ones. Some strategies to increase parent involvement include the following: ■■

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Try to have as many parents as possible involved in the planning of parent activities. The intent should be to have the activities developed and run by parents for parents. Keep the role of teachers or staff as support to the activities. Have operating rules for parent planning meetings as well. Care needs to be practiced so that all participants are heard and their opinions respected. Stay on task at the meeting; parent time is valuable and they need to feel personal accomplishment to continue their participation. Offer childcare whenever possible; many parents do not participate due to the cost of babysitting. Develop a carpool for parents who do not have transportation. Provide refreshments when appropriate (not essential); if possible, either have a fund to purchase snacks or ask participants to rotate bringing them. Some parents may prefer potluck dinners—let them choose. Provide interpreters for non-English-speaking parents or for deaf or hard of hearing participants. This expense

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should be paid for by the school as part of accessibility requirements under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (Appendix 1–A). Solicit input from all parents when developing programs, workshops, or events. Try a calling tree or e-mail lists to keep all parents informed of activities. Rotate the meeting times and days. Different meeting times may permit more parent involvement in the long run, even if their attendance cannot be consistent. Establish a parent welcome group that calls on families who are new to the school or who have a newly identified child. A parent-to-parent chat can often mean as much, or more, to the parent as a professional’s support. Be cautious that parents who make these visits and calls are good representatives of the program, having a thorough understanding of the school and services and not imposing their values related to communication modalities or instructional programs. They also must have good communication skills. Avoid using parents who are dissatisfied with the school’s services or experiencing other significant problems. Parent involvement can be summarized, both humorously and seriously, by the quote illustrated in Figure 3–2 from the Parent Leadership Associates (now available from https://www .wrightslaw.com/info/advo.fruitcake.power.htm).

DIFFICULT SITUATIONS Parent counseling and training as identified in IDEA 20041 is an important related service that can help parents enhance the vital role they play in the lives of their children. Helping

1

34 C.F.R.§300.24(b)(7).

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Partnering With Families

Parent/School Disagreement Over Individualized Education Program Services Challenges can occur when the parents and school staff disagree on type, amount, or scheduling of services. One scenario concerns parents who want more speech therapy than the school is able to provide. The issue of the academic relevance of speech production is a little confusing for all of us, particularly because this problem occurs most frequently with students who are deaf or those who have very severe hearing losses. The increase in children with cochlear implants requiring additional therapy to capitalize on the critical postimplant period is also common. Often these children use sign language to supplement speech as their established system of communication. Although the desire may be for children to have the best speech possible, each of these situations must be addressed individually recognizing the importance of input from family members as well as from the students themselves.

Request for a Specific Brand of Amplification As the range and variety of hearing instrument options increase, more choices are available for the type and style of hearing assistance technology. Parents occasionally request a certain make, model, or style of personal or classroom system for their child. Although educational audiologists make every effort to accommodate parent requests, the schools are under no obligation to provide a specific brand or style, provided that the equipment used by the school performs the necessary functions and is appropriate for the student’s needs as designated in the IEP.

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Influence of Private Provider on School Services Private providers may make recommendations with which the school does not agree. This problem occurs in a variety of situations, including specific services and types of habilitation, the recommendation of specific amplification devices, and different interpretations of a diagnosis. When a private provider recommends a specific type of therapy or intervention (such as listening and spoken language [LSL] for children with cochlear implants or a specific computer program for a student with auditory processing deficits [APDs]), schools and educational staff should remain open to suggestions as they make every effort to provide appropriate, individualized services. This effort might include the implant center providing a therapist with extra training in specialized treatment techniques. It does not mean, however, that the school is mandated to provide a certified LSL specialist as the only qualified individual to conduct the therapies. Services are directed by the IEP that must describe the needs of the student, the annual goals, and the short-term objectives, including the individual(s) responsible for providing the services and evaluating progress (see Chapter 11, Developing Individual Plans, for more on IEPs). Another area of conflict that can arise between schools and private providers relates to the diagnosis of APD and resulting recommendations for amplification. Most schools conduct assessments in a multidisciplinary manner. Academic, health, psychological, and speech-language assessment information reflecting the impact of the APD may be missing when APD is diagnosed by a private provider, as this practice can result in difficulty ascertaining the educational significance of the problem. Many audiologists who conduct APD assessments privately use extensive test batteries that may ultimately detect an abnormal finding. However, difficulty on only one subtest of a larger battery may not have enough significance to warrant special education intervention or remote microphone hearing assistance technology (RM HAT). Furthermore, the recommendation for a service, such as the use of RM HAT within the school environment, is a team decision determined during the IEP or Section 504 process. Amplification for a student with APD should first be preceded by a successful trial period to determine the actual benefits of the system. (See Chapter 6, Auditory Processing Deficits, for more on APD.) Many of the problems that occur between the private provider, parent, and school system could be remedied if all individuals worked collaboratively during the IEP process to identify student needs and resulting service recommendations. As has been emphasized, relationships are much more effective when all parties work together and use established communication practices. It is also critical that the educational audiologist or individual coordinating these meetings have accurate information on school legal obligations and current case law. (See Chapter 15, Collaborative

Chapter 3

parents to acquire the necessary skills that will allow them to support the implementation of their child’s IEP or IFSP may help avoid some of the challenging situations described in this section. More specific information on ways that parents can be involved in their child’s educational program can be found in Chapter 11, Developing Individual Plans. Not all families are easy to work with. Unfortunately, we must support difficult families and situations from time to time. There are no specific solutions to these problems, because each family and the dynamics of each situation are different. Some common challenges are identified and discussed later together with suggestions for working through them. Disputes should be dealt with carefully, maintaining sensitivity and respect for all participants involved. Sometimes difficult situations cannot be resolved, and more formal dispute resolution, mediation, or due process proceedings are necessary and can be used successfully (see Chap­ter 11 for more on this topic). However, even these meetings can take many hours, and when the financial impact of the time of the parties involved is calculated, the cost is still quite high. Ultimately, if differences remain unresolved, due process may be the only alternative.

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School–Community Partnerships, for more information and resources on this topic.)

Families That Have Difficulty Being Involved

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Families that have limited capacity to provide support for their children in the home,  have difficulty attending IEP meetings, or  do not follow through on recommendations made by the school are challenging for all of us. Whether the families are noncompliant, willing but unable, or dysfunctional, their children are often left to the schools for education and support. Completing audiological assessments, obtaining medical treatment, conducting hearing instrument fittings, and completing financial aid applications are all necessary but difficult steps when families are unable or unmotivated to follow through on needed services. It is for these children that school professionals must work together so that they are able to receive the services to which they are entitled. Educational audiologists need to be connected to their community agency network for assistance in arranging transportation to appointments or obtaining home services to help parents with appointments and the completion of financial assistance paperwork. Often these are the children who benefit the most from the school’s ability to provide comprehensive audiology support. An additional concern is poor hearing instrument use outside of the school. This problem typically occurs with children/youth whose families do not see the benefits of the hearing instrument for their child, do not encourage hearing instrument use at home, or are afraid that the hearing instrument will be broken or lost if used during out-of-school activities. Our efforts to maintain the hearing instruments at school and to demonstrate the advantage of amplification in all aspects of the child’s life are important in instilling future

The Department of Labor, in an August 8, 2019, opinion letter (https://www.dol.gov/whd/opinion /FMLA/2019/2019_08_08_2A_FMLA.pdf ), stated that the Family and Medical Leave Act (FMLA) provides for families to attend their children’s IEP meetings “if their presence is significant to their ability to provide care for their children.” While FMLA is unpaid, it is job-protected and can be intermittent. FMLA is founded on care for a person (i.e., child) with “a serious health condition” (i.e., disability eligible for special education services). The care includes attending care coordination meetings (i.e., IEP meetings) in order to “provide appropriate physical or psychological care” to the employee’s children.

self-responsibility on the part of the student. (See Chap­ ter 10, Supporting Wellness and Social-Emotional Competence, for more detailed discussions of working with students on these issues.) It is important to support families to help them become involved with their children’s education. One of the oftenoverlooked purposes of parent-to-parent connections is the opportunity for families to see positively modeled behaviors of effective parent involvement and advocacy from their peers—other families. Families that are previously unengaged may begin to move forward when they meet other parents who are taking responsibility for the education of their own children.

Differing Opinions on Communication Modality Communication modality and educational methodology remain topics in deaf education that generate a variety of opinions. Although communication modality remains the parents’ choice for their child, deaf education programs continue to reflect preferences for some options over others. It is understandably difficult for school districts to provide the full range of options from spoken language to signed English to ASL and cued speech, especially when the population of students who are deaf or hard of hearing is small. The special considerations requirements of IDEA2 focus on this topic as part of the IEP process. Differences of opinion between school staff and parents should be addressed through objective means that assess the effectiveness of the child’s communication in the current modality, alternative modalities and methodologies under consideration, as well as educational performance. The educational audiologist is a critical team member who can help in the discussion by providing objective functional data on the status and progress of auditory development and the need for additional visual input. Additionally, the necessity of objective evaluation data to monitor communication and other areas of development when guiding methodology decisions should be supported. Generally, the more delayed the child’s language, the greater the consideration for providing additional inputs, accommodations, or curricular modifications. Regardless of communication options selected by families, we should continue to emphasize that their children’s successes with the chosen method(s) are affected by the fidelity with which the family embraces and integrates the communication system into their everyday routines.

2

34 CFR §300.324 (2)(iv).

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TABLE 3–4  Eight Essential Characteristics for Individuals Working With Parents of Children With Hearing Differences 1.

Possess a basic conviction that, given an appropriate support system, people can grow and change if they so desire.

2.

Possess a nonjudgmental attitude regarding cultural and lifestyle differences.

3.

Possess an empathetic—not sympathetic—attitude (feel “with” versus feel “for”).

4.

Be a perceptive listener regarding nonverbal as well as verbal messages.

5.

Possess the basic conviction that parents can and do directly influence the outcomes of intervention; time and effort now will pay off later.

6.

Be able to accept parental expression of a variety of emotions without personalizing and becoming defensive.

7.

Be able to develop a warm, caring relationship while retaining a professional role.

8.

Respect the privacy of parents.

SUMMARY This chapter discussed the multiple facets involved when building relationships with families. Because each family is different and each situation unique, educational audiologists should rely on their experience and professional judgment along with the input of other members of the professional team to determine the most effective way to work with each family. More importantly, never underestimate the capability of families to discern the needs of their children and what is required to address them. It is the responsibility of all professionals to help parents gain the tools to be their child’s best advocate and to pass those advocacy skills on to their children. Suggestions on strategies to facilitate and maintain productive partnerships, ways to talk with families, and what to talk about with them have been presented. Matkin (1994) suggested eight essential characteristics that should be practiced when working with families that have children who are deaf or hard of hearing. These are presented in Table 3–4 and summarize the contents of this chapter well. In the end, however, there is one primary rule to remember: treat families as you would want yours to be treated. School programs can initiate an effective program where families are meaningfully involved, offering their support, and desire to create systemic educational improvement, so that all children who are deaf and hard of hearing can succeed to their highest potential.

Clark, J., & English, K. (2004). Counseling in audiologic practices: Helping patients and families adjust to hearing loss. Boston, MA: Allyn & Bacon. DesGeorges, J. (2016). Avoiding assumptions: Communication decisions by hearing parents of deaf children. American Medical Association Journal of Ethics, 18(4), 124–128. DesGeorges, J., Johnson C. D., & Seaver, L. (2013). Educational advocacy for students who are deaf or hard of hearing: The Hands & Voices guidebook. Boulder, CO: Hands & Voices Publications. English, K. (2002). Counseling children with hearing impairment and their families. Boston, MA: Allyn & Bacon. Luterman, D. (2008). Counseling persons with communication disorders and their families (5th ed.). Austin, TX: ProEd. Marschark, M. (2017). Raising and educating a deaf child (3rd ed.). New York, NY: Oxford University Press. Putz, K., Kennedy, S., Olson, S., & DesGeorges, J. (Eds.). (2017). We are Hands & Voices: Stories for families raising children who are deaf/hard of hearing. Boulder, CO: Hands & Voices. Schwartz, S. (Ed.) (2007). Choices in deafness: A parent’s guide to communication options (3rd ed.). Bethesda, MD: Woodbine House. Seaver, L. (Ed.). (2010). The book of choice: Support for parenting a child who is deaf or hard of hearing (4th ed.). Boulder, CO: Hands & Voices. Waldman, D., & Roush, J. (2010). Your child’s hearing loss: A guide for parents (2nd ed.). San Diego, CA: Plural Publishing.

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Note. From “Key considerations in the provision of family centered services” by Noel D. Matkin, 1994. Paper presented at the Colorado State Symposium on Deafness, Colorado Springs, CO.

SUGGESTED READINGS American Speech-Language-Hearing Association. (2008). Guidelines for audiologists providing informational and adjustment counseling to families of infants and young children with hearing loss birth to 5 years of age [Guidelines]. Retrieved from https://www.asha.org/policy.

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APPENDIX

3–A

Resources for Parents of Children Who Are Deaf or Hard of Hearing

Chapter 3

Alexander Graham Bell Association for the Deaf and Hard of Hearing (AG Bell) 3417 Volta Place NW Washington, DC 20007-2778 (202) 337-5220 https://www.agbell.org

Through advocacy, education, research, and financial aid, AG Bell helps children and adults who are deaf or hard of hearing (D/HH) have the opportunity to listen, talk, and thrive in society. AG Bell has chapters in the United States and international affiliates. Services include special interest for parents, Volta Voices magazine, academic journal, financial aid and scholarship awards, and many other programs.

American Association of the DeafBlind 248 Rainbow Drive #14864 Livingston, TX  77399-2048 [email protected] http://www.aadb.org

AADB is a national consumer organization of, by, and for deaf-blind Americans and their supporters. “Deaf-blind” includes all types and degrees of dual vision and hearing loss. Membership consists of deaf-blind people from diverse backgrounds, as well as family members, professionals, interpreters, and other interested supporters.

American Society for Deaf Children PO Box 23 Woodbine, MD  21797 (800) 942-2732 https://deafchildren.org

Organization that provides information and advocates for use of American Sign Language (ASL). Will provide referrals to support groups and ASL resources for parents, including ASL camps and the ASDC national conference.

Aspen Camp School for the Deaf PO Box 272 Snowmass, CO 81654 (970) 923-2511 https://www.aspencamp.org/

Summer camp emphasizing self-esteem and independence through recreation.

BEGINNINGS for Parents of Children Who Are Deaf or Hard of Hearing 156-A Wind Chime Court Raleigh, NC 27605 (919) 715-4092 https://ncbegin.org

Parent-driven group that provides emotional support and access to information, serving as an impartial central resource for families with deaf or hard of hearing children as well as deaf parents with hearing children.

Better Hearing Institute P.O. Box 1840 Washington, DC 20013 (703) 642-0580 (V/TDD) https://www.hearing.org

Organization that provides information and resources on all aspects of hearing loss, from medical to hearing instruments

Boys Town National Research Hospital 555 N. 30th Street Omaha, NE 58131 (402) 498-6511 https://www.boystownhospital.org https://www.babyhearing.org

Maintains research registry for hereditary hearing loss; fact sheets on genetics and specific syndromes. BabyHearing. org is for parents to gain information on hearing screening, hearing, communicating, preparing for school, and parenting children who are D/HH.

Central Institute for the Deaf 825 S. Taylor Avenue St. Louis, MO 63110 (877) 444-4574 ext. 135 http://cid.edu

Private oral residential and day school that publishes assess­ ment and classroom materials for professionals in deaf education.

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CueSign [email protected] https://www.cuesign.org/

CueSign believes in, supports, and promotes the importance of full, visual  access to language for deaf and hard of hearing individuals through both cued languages and signed languages in all environments.

Educational Audiology Association (EAA) 700 McKnight Park Drive Suite 708 Pittsburgh, PA 15237 (800) 460-7322 http://edaud.org

Professional organization that supports and provides infor­ mation on educational services to students with hearing loss and related auditory disorders.

Family Voices P.O. Box 37188 Albuquerque, NM 87176 (888) 835-5669 http://familyvoices.org/

A national organization and network of families and friends of children and youth with special health care needs and disabilities that promotes partnership with families—includ­ ing those of cultural, linguistic, and geographic diversity— in order to improve health care services and policies for children.

Hands & Voices P.O. Box 3093 Boulder, CO 80307 (303) 492-6283 http://www.handsandvoices.org http://handsandvoices.org/fl3/index.html

Organization dedicated to providing unbiased information and support to families of children who are deaf or hard of hearing, and professionals who serve them. Good online articles on education and legal rights.

HEAR NOW 6700 Washington Ave South Eden Prairie, MN 55344 (800) 328-8602 https://www.starkeyhearingfoundation.org/Hear-Now

Starkey Hearing Foundation’s “Hear Now” is an applicationbased program that provides hearing help to low-income Americans. Each person they help is fit with new, top-ofthe-line digital hearing aids customized to their hearing loss.

Hearing Loss Association of America 7910 Woodmont Ave., Suite 1200 Bethesda, MD 20814 (301) 657-2248 (V) https://www.hearingloss.org

Organization of individuals with hearing loss dedicated to open the world of communication through providing information, education, support, and advocacy.

House Ear Institute 2100 West Third Street, Suite 111 Los Angeles, CA  90057 (213) 770-2187 https://hei.org

Resources for information, research, and treatment for those with early childhood deafness and their families.

International Hearing Dog Inc. 5909 E. 89th Avenue Henderson, CO 80640 (303) 287-3277 https://www.ihdi.org

Nonprofit organization that trains and provides dogs at no cost to adults over 18 years old who are living alone or with other persons who are D/HH who have at least a 65-decibel (unaided) hearing loss and are able to care for the dog.

John Tracy Clinic 806 West Adams Boulevard Los Angeles, CA 90007 (213) 748-5481 https://www.jtc.org

Multiple materials in English and Spanish about listening, language, speech, and child development. Families enrolled in Worldwide Parent Education program receive personalized guidance from hearing loss specialists. Live, online video classes for groups of parents can be arranged on request.

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Laurent Clerc National Deaf Education Center/Gallaudet University 800 Florida Avenue NE Washington, DC 20002 (202) 651-5855 (TTY/Voice) https://www3.gallaudet.edu/clerc-center.html

Center provides information on topics including ASL, assistive technology, early intervention, educational advocacy (app), hearing aids, cochlear implants, deaf mentors, reading to deaf children, research, Odyssey magazine, and more.

Miracle-Ear Children’s Foundation 150 South Fifth Street Suite 2300 Minneapolis, MN 55402 (800) 241-1372 https://www.miracle-ear.com/foundation

Supports underserved Americans with a limited income and no other resources for hearing aids, such as insurance, Medicaid, Veterans Affairs, or other state or federal programs.

National Association for the Deaf (NAD) 8630 Fenton Street, Suite 820 Silver Spring, MD 20910-4500 Videophone: ■■ (301) 587-1788 (ZVRS) ■■ (301) 328-1443 (Sorenson) ■■ (301) 338-6380 (Convo) ■■ (301) 453-2390 (Purple) https://www.nad.org

Civil rights organization of, by, and for deaf and hard of hearing individuals in the United States. The advocacy scope of the NAD is early intervention, education, employment, health care, technology, telecommunications, youth leadership, and more.

National Cued Speech Association 1300 Pennsylvania Ave. NW, Suite 190-713 Washington, DC 20004 (800) 459-3529 http://www.cuedspeech.org

Organization that supports and provides information about the use of cued speech. Maintains a list of local instructors. Catalog with related materials.

National Institute on Deafness and Other Communication Disorders National Institutes of Health 31 Center Drive, MSC 2320 Bethesda, MD 20892-2320 https://www.nidcd.nih.gov

Federal institute that provides research support and resource information on multiple aspects of deafness. Links to genetic information and hereditary hearing loss registry.

Oticon Inc. 580 Howard Avenue Somerset, NJ 08873 [email protected] https://www.oticon.com/solutions/for-children/sensei

Manufacturer that provides pediatric hearing aids and hearing information.

Signing Exact English (SEE) Center 10443 Los Alamitos Blvd Los Alamitos, CA 90720 (562) 430-1467 https://seecenter.org

Nonprofit organization that provides information and support for parents and professionals on Signing Exact English communication.

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APPENDIX

3–B

Family Needs Interview for Families of Children Who Are Deaf or Hard of Hearing DIRECTIONS TO THE FACILITATOR: Many families of young children who are deaf or hard of hearing need additional information and/or support to enable them to make the best decisions regarding their child’s early intervention services. Listed below are some of the needs frequently identified by these families. This interview should be used with the family to identify areas where the early intervention program may be able to provide these additional supports. Support may take several different forms including printed materials, videotapes, web resources, referrals to other agencies, connections to other parents, and discussion. Some questions may be adequately addressed through information shared during this interview process. Child’s Name:



Date Completed:

Person being interviewed:



Relationship to Child:

TOPICS

NO

YES

NOT AT THIS TIME

Chapter 3

Interviewer:  DATE/INFORMATION PROVIDED

General Information: Would you like information in any of the following areas? 1. General growth and development 2. Playing or talking with my child 3. Teaching my child 4. Handling my child’s behavior Information about Hearing and Hearing Differences:  Would you like information in any of the following areas? 5. Normal hearing and how the ear works 6. Cause of my child’s hearing condition 7. Hearing aids and how they will help my child 8. Cochlear implants and other types of hearing devices 9. Keeping the hearing aid(s) on Communication:  Would you like information in any of the following areas? 10. Teaching my child to listen 11. Hearing differences and the effect on my child’s ability to learn to talk 12. Language development 13. Sign language 14. How my child will communicate 15. How I can communicate with my child Services and Educational Resources:  Would you like information in any of the following areas? 16. Special services available for my child 17. Communication accessible activities and programs in my community

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18. Special services available in my local school district 19. Ideas to more effectively communicate with my child’s teacher or therapist 20. Ideas to manage time regarding my child’s hearing needs and therapies 21. Other conditions my child may have Family and Social Support:  Would support in any of the following areas assist you in meeting the needs of your family and child? 22. Talking with someone in my family, or a friend, about my concerns 23. Opportunities to meet with other parents of children who are deaf or hard of hearing 24. Opportunities to meet deaf and hard of hearing adults 25. Information about parent support groups 26. Help with our family’s, or extended family’s, acceptance and understanding of the hearing difference 27. Meeting with a counselor who specializes in hearing loss issues 28. Meeting with a counselor regarding family issues

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29. Explaining my child’s hearing difference to others 30. Help with sibling issues Do you need assistance in any of the following areas? These issues and concerns may need to be referred to the case manager or other resources in the community. 1. Help locating good babysitters for my child 2. Help locating a day care program for my child 3. Help locating therapists or other specialists 4. Help with transportation 5. Funding for hearing aids 6. Funding for therapy 7. Funding for child care/respite care 8. Funding for other special equipment my child needs 9. Resources for food, housing, medical care, clothing, or transportation

Please list other topics or information that the family would like to receive or discuss:    

Source: Adapted with permission from “The Family Needs Survey” by D. Bailey and R. Simeonsson, 1988.

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APPENDIX

3–C

Childhood Hearing Loss Question Prompt List (QPL) for Parents Many parents have questions or concerns about their child’s hearing loss that they want to discuss with their audiologist. During busy clinic visits, parents may forget to ask their questions. Parents like you helped create this question sheet to help parents get the information and support they are looking for. The questions on this list are organized by topic. Some questions may matter more to you than others. If you find it helpful, you can use this list to help you remember what to ask. Circle the questions you are interested in, or write down your own questions before your clinic visit. Plan to ask your most important questions first. You can keep using this question list for as long as you like.

I. Our Child’s Diagnosis What kind of hearing loss does my child have? Why does my child react to some sounds? Are there tools to help me and others experience what hearing is like for my child? Will my child’s hearing get better/worse over time? Do hearing aids fix hearing loss in the way glasses fix vision problems? How do you and my family decide what technology, if any, is right for my child? Is it likely that my child’s speech will be affected? We often feel overwhelmed with the decisions we have to make. Can you help us prioritize these decisions? Are there related medical concerns I should know about? Why is it recommended that we see a geneticist? I’m finding it hard to come to terms with the diagnosis and what it might mean for my child and family. How can I get support?

Chapter 3

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

II. Family Concerns 12. 13. 14. 15. 16. 17. 18.

How can I share the importance of hearing devices with family and others? What resources are there to help us pay for our child’s hearing needs? What can we do at home to encourage our child’s communication development? What resources are there to build children’s confidence, resilience, social skills? If we want to learn sign language, how/where do we start? What are some effective ways to get my child’s attention and communicate? What should I be looking for at home to know if my child is making appropriate progress?

III. Management of Devices How much should my child use his/her hearing devices? How do I take care of the hearing devices? What strategies do parents use to keep the devices on a child’s ears? What do we do if the hearing aids stop working? How can I encourage my child to feel confident about using hearing devices? Will it take a while for my child to get used to his/her hearing aids? Should we take the hearing aids off when our child naps, breastfeeds, etc? When the hearing aids are touched, does the feedback noise bother our child?

IV. Support Systems, Now and in the Future 27. I’d like to talk to other people in our situation. How can I meet other parents with children with a hearing loss, and/or adults who are deaf or hard-of-hearing? 28. What agencies are available to help our family? 29. If I wanted support from a social worker or family counselor, how would I obtain a referral? 30. How can I help our childcare provider support our child’s communication needs? 31. Do children with my child’s level of hearing typically go to their local school? 32. What kind of help will my child need if he/she wants to participate in sports, music, and other activities?

V1.00/2017-12/2017 © Sonova AG All rights reserved

19. 20. 21. 22. 23. 24. 25. 26.

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CHAPTER

4

Hearing Screening and Identification CONTENTS

Chapter 4

State Hearing Screening Mandates Screening Requirements in Private Schools, Charter Schools, and Other Nontraditional Education Settings Purposes of Hearing Screening and Identification Programs Professional Guidelines  ■  Age Considerations  ■  Prevalence Considerations Resources for Hearing Screening and Identification Programs Personnel and Time  ■  Scheduling Considerations Screening and Identification Program Considerations Early Childhood  ■  School-Age Children and Youth

“I hear the beep!”

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CONTENTS 

(Continued) (Continued )

Chapter 4

Screening and Identification Procedures Visual Inspection  ■  Auditory Brainstem Response  ■  Otoacoustic Emissions  ■  Pure-Tone Audiometry  ■ Tympanometry ■  Behavioral Observation Screening and Identification Protocols Infants and Young Children  ■  School-Age Children and Youth Hearing Screening and Monitoring Children Who Cannot Respond to Traditional Measures Screening Personnel Audiologists  ■  Speech-Language Pathologists  ■  Parent Volunteers, School Nurses, and Paraprofessionals  ■  Training of Support Personnel Screening Equipment and Maintenance Screening Equipment  ■  Equipment Maintenance/Calibration  ■  Infection Control Screening Environment Location of the Screening Room  ■  Noise Levels  ■  Other Factors Organization of Screening and Identification Programs Scheduling of the Screening  ■  Activities Prior to the Screening  ■  Activities During the Screening Follow-Up Procedures Follow-up Screening for Middle Ear Conditions and Medical Referrals  ■  Referrals for Audiological Evaluations  ■  Educational Screening Data Management and Reporting Determining the Effectiveness of Hearing Screening and Identification Programs Data From Screening Program  ■  Sensitivity and Specificity  ■  Cost Effectiveness Summary Suggested Readings and Resources Appendices 4–A State Hearing Screening Laws for Children in Schools (Text) 4–B HEAR Checklist (Text/Online) 4–C Record of Ear and Hearing Problems (Online) 4–D Basic Hearing Problems Questionnaire for Students With Developmental Delays (Text/Online) 4–E Preparation Checklist for Preschool and School Hearing Screening (Online) 4–F Parent Notification Letter for Hearing Screening (Online) 4–G Class Hearing Screening Results Record Forms (Online) 4–H School Hearing Rescreening/Referral List (Online) 4–I Sample Teacher Notification of Screening Results (Online) 4–J Sample Parent Notification of Screening Results—Pass (Online) 4–K Sample Parent Notification of Screening Results—Recheck (Online) 4–L Sample Parent Letter to Refer Child for Further Audiological Evaluation (Online) 4–M Sample Medical Referral Letter and Return Medical Referral Form (Online) 4–N Sample Medical Referral Form (Physician) (Online)

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KEY TERMS Hearing screening, state screening laws, sensitivity, specificity, incidence, prevalence, pure tone, tympanometry, otoacoustic emissions (OAEs), child find, high-risk checklists, noise-induced hearing loss, otitis media, protocols

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Variances in state hearing screening mandates emphasize the importance for educational audiologists to know the laws regarding hearing screening in their states. Hearing screening is the starting point for potential services for deaf and hard of hearing students. The prevalence of reduced hearing increases as children age; from about 2 to 3 per 1,000 at birth to 4 to 5 per 1,000 at school age (National Health and Nutrition Examination Survey [NHANES]) and to 9 to 10 per 1,000 (White, 2019) in teens including 12% of 12- to 19-year-olds with documented noise-induced threshold shifts (NHANES, 2009–2010). Otoacoustic emissions (OAEs) have increased the effectiveness of screening programs for young children and other children who cannot respond to traditional play conditioning or pure-tone screening methods. Advancements in wireless pure-tone screening technology will reduce background noise issues and increase screening efficiency using automated protocols that provide flexible programming for various populations as well as threshold options to 0 dB hearing level (HL).

The initial step in a school-based audiology program is to ensure there is a method of identifying those children who have reduced hearing or other auditory disorders. This is typically done, at least in part, through a hearing screening and identification program. A hearing screening program’s purpose is to identify those children who might have reduced hearing, whereas a hearing loss identification program should identify those who definitely have reduced hearing. Identification procedures are required by Individuals with Disabilities Education Act (IDEA) under the definition of audiology.1 A hearing screening program should separate a large population of children into two groups—those who have normal results (pass) and those who have abnormal results who need further testing (refer). Because a hearing loss identification program is designed to determine the presence or absence of reduced hearing, follow-up procedures beyond hearing screening must be included. This chapter addresses procedures specific to hearing screening and identification, and Chapter 5, Assessment, focuses on diagnostic procedures.

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Questions to be discussed when developing and implementing a hearing screening and identification program include the following: What are the existing state and federal mandates for hearing screening? What are the purposes of the hearing screening and identification program? What resources are available to run the program? What do professional guidelines recommend for screening protocols? What test procedures will be used for screening and for identification? What pass/refer criteria will be used? What children will be screened? How will children who cannot respond to traditional techniques be screened? What are the criteria (noise level, visual distractions) for the screening room? What personnel will be needed for the screening and identification program? What equipment will be necessary, and how will it be calibrated and maintained? Who will organize the screening and identification program? What follow-up procedures will be used for rescreening referrals and absentees? What recordkeeping and reporting are required, and how will it be accomplished? How will the effectiveness of the screening and identification program be evaluated?

Although it may be difficult to provide specific answers for all of these questions, this chapter addresses each one and provides options that the educational audiologist and other screening team members can consider when designing and implementing a hearing screening and identification program. Issues related to screening for auditory processing are addressed in Chapter 6, Auditory Processing Deficits.

Chapter 4

Hearing Screening and Identification

STATE HEARING SCREENING MANDATES State laws that govern hearing screening vary from no requirement to comprehensive protocols that require screening at multiple grade levels with specific procedures and follow-up. Appendix 4–A contains a summary of state hearing screening requirements. Statutes contain general provisions, while subsequent regulations provide the necessary specifications required to implement and carry out the law. The Centers for Disease Control and Prevention (CDC) collects and reports data on the Early Hearing Detection and Intervention (EHDI) Program, a federally funded initiative

1

34 C.F.R. §300.

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that includes screening of infants for hearing loss, audiological evaluation to confirm hearing status, and referral to early intervention services. The 2016 CDC EHDI Summary (May 2018) reported an average of 98% of infants were screened according to 56 respondents from 49 states, seven territories, and the District of Columbia. The EHDI management system works from state-level laws and regulations that articulate local policies and procedures. In 2019, 43 states (plus the District of Columbia, Guam, and Puerto Rico) had statutes related to newborn hearing screening (http://www.infanthearing.org, retrieved June 30, 2019). According to the InfantHearing.org website (retrieved June 30, 2019), only 28/43 states required screening of all babies; some states set the compliance standard as low as 85%, meaning that so long as 85% of hospitals in the state conducted newborn hearing screening, the state would be considered “in compliance” with the federal mandate. Other states manage newborn hearing screening programs without a state mandate. Systematic early childhood hearing screening after the newborn period until school age does not exist primarily due to the logistical challenge of capturing this age group. In addition to family and pediatric physicians and clinics, entities that provide screening for young children include public health departments (e.g., Early Periodic Screening, Diagnostic, and Treatment [EPSDT] services), federally and/or state-funded preschools (e.g., Head Start), school district Child Find programs, and some community agency or service groups. While professional standards guide hearing screening in this population, those standards may vary among professional groups (e.g., physicians, public health nurses, and audiologists) as well as by state. Most states require hearing screening for school-age children at least at kindergarten entry, but, as with newborn hearing screening legislation, there is significant variability in the specificity of the laws (NASBE, n.d.). These variances emphasize the importance of educational audiologists being knowledgeable of the mandates regarding hearing screening in their states.

Screening Requirements in Private Schools, Charter Schools, and Other Nontraditional Education Settings Screening students in private schools, charter schools, online and other nontraditional settings often presents unique

The Centers for Medicare and Medicaid Services (CMS) recommend that children enrolled in Medicaid should receive hearing screenings at each well-child checkup. The program known as EPSDT provides a comprehensive benefit to ensure that children are identified and treated as early as possible.

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challenges. Generally, state screening mandates apply to all publicly funded school programs, including alternative and charter schools that are part of the local school district. Juvenile detention facilities and other state-operated programs that contain youth who are at the grade levels identified in the state screening regulations also need to be screened. Private school students should also have the opportunity to participate in public school screening programs. Depending on each state’s regulations, public schools may provide ■■ ■■

■■

the services at private schools; equipment and training for the private schools to conduct their own screening; or screening to private school students (including those attending online schools) at a nearby public school or another neutral site.

Currently, Internet-based hearing screening programs continue to have too many uncontrolled variables to be a valid and reliable alternative to traditional live screening. Students in all of these settings require access to hearing identification as part of the local federally mandated Child Find program for students suspected of having a disability.

PURPOSES OF HEARING SCREENING AND IDENTIFICATION PROGRAMS When designing a hearing screening program, the educational audiologist must collaborate with the school nurse and/or other appropriate school staff. Because health screenings are generally completed with all members of the targeted student group, they are considered a population-based procedure rather than a special education requirement based on individual need. The audiologist’s responsibility is to help ensure that the screening procedures utilized will result in an effective system that distinguishes children who have normal hearing from those who may have reduced hearing and who are in need of follow-up testing to identify whether reduced hearing is present. The key professionals involved should have the specific outcomes of the program clearly in mind. Table 4–1 describes the steps in the screening and identification process. Screening programs must be properly evaluated to demonstrate acceptable performance. Parameters that are commonly used to evaluate the screening and identification program are sensitivity and specificity. A good screening program should have a high sensitivity rate so that overall referral rates are not excessive, balanced with a high degree of specificity so that reduced hearing is not missed. Sensitivity and specificity, as used to evaluate program effectiveness, are discussed later in this chapter.

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Step

Goal

Procedure

Outcome

Step 1

SCREENING: Separate individuals with normal hearing from those with a possible hearing loss.

Screening protocol based on state or local regulations and guidelines. The procedures may include a second screening using the same procedures or may add additional procedures such as threshold screening or immittance.

Pass or refer

Step 2

IDENTIFICATION of hearing loss: Confirm whether reduced hearing is present; describe some preliminary components of the hearing status.

Identification protocol includes procedures that inform follow-up assessment including threshold screening, immittance, and otoacoustic emissions. These procedures should be conducted by an audiologist or a trained audiometric technician and require parent permission. They are conducted in the school or other screening setting.

If findings are positive for reduced hearing: refer to audiologist for audiological assessment, physician for medical assessment, and/ or refer to special education for multidisciplinary evaluation. If findings are negative for reduced hearing, student may be flagged for periodic screening or cleared from referral list.

Definitions Sensitivity: the ability of the screening procedure to identify the target population accurately (e.g., hit rate or number of individuals who have reduced hearing). Specificity: the ability of the procedure to not identify (e.g., to pass) those who truly do not have the disorder the screening program is designed to identify.

Professional Guidelines Considerations for the development of hearing and identification programs are detailed in professional guidelines of the American Academy of Audiology (AAA), the American Speech-Language-Hearing Association (ASHA), and the Educational Audiology Association (EAA). These guidelines contain specific referral criteria and other recommendations for each target age group. Audiologists should review the following documents when developing or revising their protocols: ■■ ■■

■■

Childhood Hearing Screening (AAA, 2011); Joint Committee on Infant Hearing Position Statement: Principles and Guidelines for Early Hearing Detection and Intervention Programs (JCIH, 2007, 2019); and Hearing Screening Advocacy Statement (EAA, 2009).

Age Considerations A major concern for infants, toddlers, and preschoolers is the development of language, communication, speech, and

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cognitive skills. Most hearing screening programs for this age group will have as their goal the detection of potential hearing differences that may affect the development of these skills. Screening may include procedures to identify otitis media due to its prevalence at these younger ages. If hearing loss has a later onset (e.g., school-age), or fluctuates due to otitis media, the potential to develop, or be at risk for developing, language, communication, and listening problems remains. These delays are often manifested by poor academic performance, communication challenges, and/or social and behavior concerns. As a result, some screening programs for school-age children will have a broader goal of identifying auditory and listening problems that include auditory processing abilities. The increase in recreational noise exposure in teens and the need for hearing loss prevention awareness and education has generated a greater interest in the identification of noise-induced hearing loss (NIHL). As a result, screening protocols that target the identification of hearing loss in the 3000 to 6000 Hz range are recommended for this age group (Johnson & Meinke, 2008; Meinke & Dice, 2007).

Chapter 4

TABLE 4–1  Screening and Identification Process

Definitions Prevalence: number of existing cases of a specific disease or condition in a given population at a given time. Incidence: frequency of occurrence, expressed as the number of new cases of a disease or condition in a specified population over a specified time period (Stach, 2019).

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Prevalence Considerations Prevalence data regarding reduced hearing, as identified in Table 4–2, vary significantly due to the definitions and referral criteria used. Efficacy data on whether a particular hearing level results in functional communication challenges is not well documented in the literature. While the functional ability of an individual with reduced hearing is specific to the unique contributing characteristics of that person, there is evidence that any level of reduced hearing can result in hearing, listening, behavior, and communication problems (le Clercq et al., 2019). In addition to state guidelines, the philosophy of the school district and of the audiologist will play an important role in determining the components included in the screening and identification program, the specific criteria for referral, and the protocol for follow-up. For example, the audiologist’s belief about the educational impact of minimal and fluctuating conductive hearing losses may affect the screening level used for pure-tone screening and the inclusion of immittance screening in the program, or interest in NIHL may affect the frequencies used for screening. Likewise, the belief about the efficacy of the evaluation and treatment of auditory processing disorders will dictate what attempts will be made to identify these disorders. The reports on prevalence of reduced hearing from the CDC’s National Health and Nutrition Examination Surveys

(NHANES) are excellent resources for educational audiologists who need data and sociodemographic characteristics among children in the United States. The prevalence data from NHANES III study are summarized in Table 4–2. A followup study (Niskar et al., 2001) analyzed the NHANES III data for NIHL, concluding that 12.5% of children 6 to 19 years old had NIHL in one or both ears. Males had a greater prevalence than females and older students more than younger ones. Screening at 6000 Hz was recommended to identify NIHL. Su and Chan (2017) conducted an analysis of NHANES demographic and audiometric data from NHANES III to NHANES 2009 to 2010. Table 4–3 summarizes the hearing loss prevalence data for four categories: pure-tone average (.5, 1 and 2 kHz) thresholds greater than or equal to 20 dB HL and 15 dB HL in one or both ears, high-frequency pure-tone average (HFHL) (3, 4, 6, and 8 kHz or 3, 4, and 6 kHz) greater than or equal to 15 dB HL, and evidence of a noise-induced threshold shift (NITS). These findings illustrate the significant difference in prevalence between the 20 dB and 15 dB HL criteria as well as the relatively stable prevalence over time at 20 dB HL versus varying prevalence at 15 dB HL and 15 dB HFHL, a potential factor when determining screening levels. The data also show a decrease in prevalence of NITS in the 2009 to 2010 findings. The study findings reported that nonwhite race/ethnicity and low

Chapter 4

TABLE 4–2  Summary of Reported Hearing Loss Prevalence Data in School-Age Children Prevalence

Definition

Source

3%

Bilateral hearing loss of 16 dB HL or greater (better ear average), unilateral, or high-frequency hearing loss

Ross, Brackett, & Maxon, 1991

5.9% (second grade) 11.3% (eighth grade) 12% (twelfth grade)

Hearing thresholds above 25 dB HL on at least one of six frequencies (2000, 4000, and 8000 Hz, combined ears)

Montgomery & Fujikawa, 1992

14.9%

≥16 dB HL low- or high-frequency average loss Low frequency: 7.1% (5.6% unilateral, 1.5% bilateral) High frequency:12.7% (9.6% unilateral, 3.1% bilateral) ≥16 dB HL low- and high-frequency average loss

Niskar, Keiszak, Holmes, Esteban, Rubin, & Brody, 1998 (NHANES III)

4.9% 11.3%

2.1%

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Bilateral SNHL (20–40 dB HL) Unilateral SNHL (≥20 dB HL) HF SNHL (>25 dB HL at two or more frequencies above 2K, one or both ears TOTAL MINIMAL HL Conductive HL all other degrees of HL TOTAL HL All hearing loss based on categories below: Bilateral SNHL (≥20 dB HL PTA) Unilateral SNHL (≥35 dB HL PTA) High frequency SNHL (PTA ≥35 dB HL) Chronic conductive (bilateral or unilateral) All other HL (minimal HL requiring monitoring not included in previous categories)

1% 3%

Bess, Dodd-Murphy, & Parker, 1998

1.4% 5.4% 3.4% 2.5% 11.3% .33% .15% .05% .09%

Johnson for Colorado Department of Education, 2005

1.4%

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TABLE 4–3  National Health and Nutrition Examination Surveys (NHANES) Summary of Hearing Loss Prevalence in 12- to 19-year-olds, 1988 to 2010 (Su & Chan, 2017) PTA ≥20 dB

HL ≥15 dB

HFHL ≥15 dB

NITS

NHANES III (1988–1994)

4%

17%

15.5%

15.8%

NHANES (2005–2006)

5%

20%

18%

16%

NHANES (2007–2008)

5%

22.5%

20%

17.5%

NHANES (2009–2010)

4.5%

15.2%

12%

12.8%

Note. HFHL, high-frequency hearing loss; HL, hearing level; NITS, noise-induced threshold shift; PTA, pure-tone average.

RESOURCES FOR HEARING SCREENING AND IDENTIFICATION PROGRAMS Personnel and Time Resources available for screening and follow-up will impact the development and implementation of a hearing screening program. Personnel and time are critical factors to be considered in determining the scope and protocol of the program. Regardless of the desire of an audiologist to identify all levels of reduced hearing and particularly those that are educationally significant, it can be frustrating to screen for these problems when resources for follow-up are not available. In fact, screening without adequate follow-up can potentially cause more harm than if the screening was not done. If follow-up testing is significantly delayed or is not done at all, teachers and parents may believe that a child who actually has a hearing problem has normal hearing ability. Likewise, if teachers and parents are aware that a child has referred from a hearing screening procedure, they may blame hearing loss for all difficulties the child is having when, in fact, other reasons for the academic problems may exist.

Scheduling Considerations The educational audiologist must work closely with the schools, staff, and others involved in the screening program and be sensitive to their needs. Even the best hearing screening and identification program will experience failure if the screening or follow-up is scheduled on the same day as an assembly or other school activity. Teachers who do not understand the importance of the hearing screening program or the protocol that will be used may object to having their classes participate in the screening. Also, because of the fluctuating nature of some hearing conditions, the training and experience of the screeners, and the environments in which screening is conducted, it is unlikely that all of the children who have hear-

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ing problems will be identified. It is, therefore, critical that the audiologist maintain contact with teachers, school nurses, and parents to encourage questions about the listening behaviors of specific children and referrals for additional testing.

SCREENING AND IDENTIFICATION PROGRAM CONSIDERATIONS Early Childhood Screening programs to detect reduced hearing among school-age children have existed in most school systems in the United States for many years. As discussed previously, it is also important for educational audiologists to be involved in the periodic early childhood screening of infants and toddlers to facilitate early identification and intervention for children with reduced hearing. Regardless of the state agency responsible for identification and services to infants and toddlers under Part C of IDEA, educational audiologists should serve as consultants and provide resources for the program. However, when the education agency is responsible for these services, it is imperative that educational audiologists be directly involved in developing, implementing, and monitoring the hearing screening program for infants and toddlers. Regardless of the role played by educational audiologists in such programs, they should be aware of the screening protocols appropriate for infants and toddlers. The Joint Committee on Infant Hearing (JCIH) 2007 Position Statement (JCIH, 2007) outlined guidelines for EHDI programs that include procedures for hearing screening, confirmation of hearing loss, and continued surveillance of infants and toddlers who are at risk for hearing loss. Currently, hearing screening for infants, toddlers, and preschoolers may be promoted by a variety of options, including ■■ ■■ ■■

■■ ■■

Chapter 4

socioeconomic status were risk factors for reduced hearing. See Chapter 12 for more information about NIHL.

high-risk checklists; periodic early childhood hearing screening; Child Find (discussed under School-Age Children and Youth); auditory developmental checklists; and education of parents, physicians, and other professionals.

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High-Risk Checklists

Periodic Early Childhood Hearing Screening

With the widespread implementation of universal newborn hearing screening, high-risk checklists now play a primary role in identifying those infants who may pass newborn screening but need ongoing audiological monitoring to identify late-onset, progressive, or fluctuating hearing loss associated with certain conditions. Risk indicators that need to be monitored are identified in Table 4–4.

Universal newborn hearing screening has greatly enhanced the early identification of various hearing disorders. However, late-onset and progressive hearing losses are not identified at birth, and conductive hearing losses fluctuate. In addition, there are children lost to follow-up with unknown hearing status. Ideally all children, birth through age 7 years, should receive periodic, ideally annual, hearing screenings to identify these potential conditions. Ensuring these annual screenings in the early childhood years is difficult because the primary established screening programs are generally limited to Early Head Start, Head Start, and Parents as Teachers (PAT). Children seen through Child Find programs receive hearing screenings, but it is a referral program rather than population-based screening. Although educational audiologists may not have a direct role in EHDI programs, they are an essential component to supporting follow-up, including hearing screening through Child Find programs, assessment, and intervention. Educational audiologists should educate physicians, health departments, and early childhood care agencies regarding the importance and necessity of annual screenings in order to increase community, statewide, and national support for this standard of care. This education will have the added advantage of encouraging hearing screenings during routine, wellbaby checks. The EAA has recommended specific roles for educational audiologists in the document, “Early Detection & Intervention of Hearing Loss: Roles and Responsibilities for the Educational Audiologist” (http://edaud.org).

Otitis Media

Chapter 4

Otitis media remains one of the most common childhood health conditions for which screening of infants and toddlers for associated hearing loss should be a priority. Data have shown that about 90% of all children will have otitis media with effusion (OME) in the early childhood years (Tos, 1984), with 50% having OME during their first year of life and more than 60% by 2 years of age (AAP, 2004). As part of their research on language development and academic achievement in children with OME, Roberts, Burchinal, and Zeisel (2002) conducted a comprehensive literature review categorizing studies by the areas of language, speech, auditory processing, and learning implications, with a general conclusion of the research findings (Table 4–5). The summary is a good reminder of the research parameters and variability of performance in children, especially those who do not have reduced hearing associated with OME. Educational audiologists should refer to the American Academy of Pediatrics’ revised Clinical Practice Guideline, The Diagnosis and Management of Acute Otitis Media (2013), and the American Academy of Otolaryngology-Head and Neck Surgery Foundation (February 1, 2016) for specific followup and treatment recommendations for acute otitis media.

Auditory Developmental Checklists It is important for educational audiologists to continue to be alert to the concerns that parents and other caregivers have

TABLE 4–4  Risk Indicators Associated With Permanent Congenital, Delayed-Onset, or Progressive Hearing Loss in Childhood ( JCIH, 2007) 1. Caregiver concern regarding hearing, speech, language, or developmental delay 2. Family history of permanent childhood hearing loss 3. Neonatal intensive care unit stay of greater than 5 days or any of the following regardless of length of stay: extracorporeal membrane oxygenation (ECMO), assisted ventilation, exposure to ototoxic medications (gentamicin and tobramycin) or loop diuretics (furosemide or Lasix), and hyperbilirubinemia requiring exchange transfusion 4. In utero infection, such as cytomegalovirus, herpes, rubella, syphilis, or toxoplasmosis 5. Craniofacial anomalies, including those involving the pinna, ear canal, ear tags, ear pits, and temporal bone anomalies 6. Physical findings, such as white forelock, associated with a syndrome known to include a sensorineural or permanent conductive hearing loss 7. Syndromes associated with hearing loss or progressive or late-onset hearing loss, such as neurofibromatosis, osteopetrosis, and Usher syndrome; other frequently identified syndromes include Waardenburg, Alport, Pendred, and Jervell and Lange-Neilson syndromes 8. Neurodegenerative disorders, such as Hunter syndrome, or sensory motor neuropathies, such as Friedreich ataxia and CharcotMarie-Tooth syndrome 9. Culture-positive postnatal infections associated with sensorineural hearing loss, including confirmed bacterial and viral (especially herpes viruses and varicella) meningitis 10. Head trauma, especially basal skull or temporal bone fracture requiring hospitalization 11. Chemotherapy

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Area

Findings

References

OME and Auditory Processing

“Difficult to conclude or refute a link between OME and central auditory processing” (p. 113)

Folsom, Weber, & Thompson, (1983); Anteby, Hafner, Pratt, & Uri (1986); Gunnarson & Finitzo (1991); Moore, Hutchings, & Meyer (1991); Pillsbury, Grose, & Hall (1991); Hall & Grose (1993); Hall & Grose (1994); Hall, Grose, & Pillsbury (1995); Hogan, Meyer, & Moore (1996); Hall, Grose, Dev, & Ghiassi (1998); Hall, Grose, Dev, et al. (1998); Moore, Hine, Jiang, et al. (1999); King, Parsons, & Moore (2000); Hogan & Moore (2003); Knudsen (2002)

OME and Speech

“Not an indication that OME represents a significant risk to speech production in otherwise healthy children” (p. 114)

Shriberg, & Smith (1983); Eimas & Clarkson (1986); Roberts, Burchinal, Koch, et al. (1988); Paden, Matthies, & Novak (1989); Nittrouer (1996); Mody, Schwartz, Gravel, & Ruben (1999); Paradise, Dollaghan, Campbell, et al. (2000); Shriberg, Friel-Patti, Flipsen, & Brown (2000); Shriberg, Flipsen, Thielke, et al. (2000); Paradise, Feldman, Campbell, et al. (2001); Campbell, Dollagahan, Rockette, et al. (2003); Paradise, Dollaghan, Campbell, et al. (2003)

OME and Language

“OME-language linkage continues to be open to some debate” (p. 115)

Vernon-Feagans, Manlove, & Volling (1996); Vernon-Feagans, Emanuel, & Flood (1997); Feldman, Dollaghan, Campbell, et al. (1999); Maw, Wilks, Haarvey, et al. (1999); Rovers, Straaatman, Ingels, et al. (2000); Paradise, Dollaghan, Campbell, et al. (2000); Paradise, Feldman, Campbell, et al. (2001); Casby (2001); AHRQ (2002); Roberts, Burchinal, & Zeisel (2002); Vernon-Feagans, Hurley, & Yont (2002); Feldman, Dollaghan, Campbell, et al. (2003); Paradise, Feldman, Campbell, et al. (2003); Paradise, Dollaghan, Campbell, et al. (2003)

OME and Academics, Attention, and Behavior

“Data linking a history of OME to later academic skills, attention and behavior continue to be mixed” (p. 116)

Roberts, Sanyal, Burchinal, et al. (1986); Feagans, Sanyal, Henderson, et al. (1987); Roberts, Burchinal, Collier, et al. (1989); Teele, Klein, Chase, et al. (1990); Arcia & Roberts (1993); Lous (1993); Feagans, Kipp, & Blood (1994); Gravel & Wallace (1995); Paradise, Feldman, Colborn, et al. (1999); Roberts, Burchinal, Jackson, et al. (2000); Minter, Roberts, Hooper, et al. (2001); Roberts, Burchinal, & Zeisel (2002)

Chapter 4

TABLE 4–5  Summary of Research Pertaining to Language, Speech, Auditory Processing, and Learning Implications of Otitis Media With Effusion (OME)

Note. From Roberts et al. (2002).

about the status of a child’s hearing. While questionnaires as an independent screening tool have been found to be unreliable (Munoz, Caballero, & White, 2014), they can be useful in educating parents and caregivers about the expected auditory and communication behaviors of their young children at specific ages as well as in identifying potential delays. Chapter 9 contains various auditory development checklist tools. These checklists should not be used to screen hearing, though problems noted on a checklist could indicate the need to screen or rescreen hearing.

School-Age Children and Youth Preschool and school-age children will typically be referred for hearing screening through one of the following processes: ■■ ■■ ■■

school-wide hearing screening; “Child Find” and special education hearing screening; or teacher, parent, or physician referrals.

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School-Wide Hearing Screening The concept of school-wide hearing screening for schoolage children is universal, but the specific grades screened vary from state to state, and often from program to program. The National Association of State Boards of Education reports (NASBE, n.d.) 34 states including the District of Columbia have state school-age screening mandates (see Appendix 4–A for listing of state requirements). Most of the states recommend screening in the elementary grades with kindergarten and first grade being the most frequent grades screened. Beyond the first grade, school-wide screening tends to occur every other year, with fewer students being screened at the secondary level.

“Child Find” and Special Education Hearing Screening “Child Find” screening and identification refers to free, community-based health and developmental screenings for children, birth to age 21 years. Schools are responsible for

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Child Find (a) General. (1) The State must have in effect policies and procedures to ensure that-(i) All children with disabilities residing in the State, including children with disabilities who are homeless children or are wards of the

Chapter 4

providing this program under Part B (3-21) of IDEA,2 while screening for a child from birth to age 3 years depends on the state lead agency for Part C and how the programs are set up. Child Find screenings are usually focused on infants, toddlers, and preschool-age children because there are no universal programs that lead to identification of disabilities for this age group. However, students in out-of-school placements up to age 22 years (or whatever age the state establishes for students to exit out of special education) also have access to the Child Find process. Child Find screenings include developmental (speechlanguage, cognitive, motor, social) as well as health (general health, vision, hearing) components and, as such, are usually conducted by a team of professionals who have expertise in these early childhood development and health areas. Audiologists, school nurses, or trained paraprofessionals may conduct the hearing screening component. However, since the screening often includes a full range of procedures designed to “identify” auditory problems that may be impacting the child’s development, audiologists may choose to work these screenings. These children also often require more diagnostic skill due to their age and other developmental factors. Referrals may be generated by parents, physicians, childcare providers, public agencies, or others who identify the concern. Children identified with disabilities through the Child Find process are generally referred to special education for eligibility determination. In many states, all students referred for special education are required to have a vision and hearing screening prior to their psychoeducational evaluation. This practice is useful because the screenings can facilitate detection of sensory deficits that might interfere with assessment and/or relate to the child’s performance, ultimately affecting educational eligibility, services, and placement. It is also advantageous to screen the hearing of all special education students annually to prevent an unidentified hearing from potentially interfering with their educational progress.

Teacher, Parent, or Physicians Referrals Referrals from teachers, parents, or physicians are critical in helping to identify children with auditory disorders. Traditional school-wide hearing screening programs may miss stu-

STATE, and children with disabilities attending private schools, regardless of the severity of their disability, and who are in need of special education and related services, are identified, located, and evaluated.

dents who are absent when the screening occurs, those not in the grades routinely screened, or students who move into the school mid-year. Also missed will be students who have fluctuating hearing levels but who had normal hearing during the mass screening and those with auditory processing disorders. Mass screening programs may also mistakenly pass some children who have reduced hearing (false-negative responses). It is important to encourage referrals from teachers, parents, and physicians, and it is helpful to have information about behaviors that may indicate that a child has a hearing problem to facilitate the referral process. To supplement referrals for hearing screenings, some school districts may use hearing behavior checklists to encourage referrals from parents, teachers, or other school personnel. (See Appen­ dix 4–B for the HEAR checklist of these behaviors, also useful for inservice training.) To identify children with chronic middle ear problems or known sensorineural hearing losses, it is often helpful to ask parents to complete a hearing history form (Appendix 4–C) when they enroll their child in school. Although designed to screen children for central auditory processing problems, the Fisher’s Auditory Problems Checklist (Fisher, 1985) could also be adapted to obtain referrals from teachers for children suspected of having hearing or listening problems (available from http://edaud.org).

SCREENING AND IDENTIFICATION PROCEDURES Procedures used in hearing screening and identification programs vary depending on the age and development of the child or youth, the goals of the program, and the resources available to the program. Prieve, Schooling, Venediktov, and Franceschini (2015) completed an evidence-based systematic review on the accuracy of pure-tone and otoacoustic emission (OAE) screening for identifying hearing loss in preschool and school-age children. While they found that both procedures identified reduced hearing, studies that compared both procedures in the same population found that the pure-tone screening had a higher sensitivity than OAE screening and was therefore considered the preferred procedure. The most common procedures that are included

2

34 CFR §300.111.

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■■

■■

Supplementary Procedures (High-risk factors and history generally are in the student’s health record; risk factors may be noted at screening for school-age populations. Auditory development checklists are typically part of the assessment for the special education referral.) High-Risk Indicator Checklist Auditory Developmental Checklist History Direct Procedures Auditory Brainstem Response Otoacoustic Emissions Pure-Tone Audiometry Tympanometry

Supplementary screening procedures are meant to provide additional information to the results obtained from the direct methods and should never be used in isolation as a screening method. For infants and children unable to consistently respond to behavioral procedures, physiological screening tests are the preferred method of screening. For all age groups, present OAEs can rule out hearing levels greater than 30 to 40 dB HL and abnormal middle ear function, and acoustic immittance is invaluable in further determining the status of the middle ear system. Referral criteria for the various screening procedures should be based on professional guidelines, the goals of the screening program, and any state laws that must be followed. For example, if a school district has as its goal the identification of every hearing loss that might be educationally significant, including minimal hearing losses, a screening level of 15 dB HL may be selected by the district. But if the district wants to identify only those losses that have a high likelihood of being educationally significant, a higher screening level, such as 20 dB HL, may be chosen.

Visual Inspection Visual inspection can be as simple as looking at the ear to identify external structural abnormalities or ear canal drainage. Any abnormalities should be noted on screening forms so that the information can be reviewed by appropriate personnel and subsequent decisions regarding follow-up made. A more sophisticated visual inspection involves use of otoscopy, a procedure requiring specific training as well as an otoscope. When otoscopy is performed, further information about ear canal abnormalities, possible foreign objects, and the condition of the tympanic membrane can be obtained. Otoscopy may be employed when nurses or audiologists are involved in more targeted screening programs such as Child Find screening.

Auditory Brainstem Response Auditory brainstem response (ABR) and automated auditory brainstem response (AABR) are physiological procedures utilized for hearing screening based on the brainstem’s

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response to sound. Soft clicks are presented to the ear via earphones or a probe, while electrodes, strategically placed on the head, record the brain’s response to sound. Because of the technique required in administration and interpretation of this procedure, it is not practical as a screening procedure. However, AABR, which is fully automated and norm referenced for newborn screening, permits a variety of personnel to perform the procedure with a high degree of accuracy and reliability. When used as a screening procedure, AABR primarily detects hearing losses that are greater than 30 dB in the frequency region above 1000 Hz. The ABR is also sensitive to the stimulus intensity so that degree of hearing loss can be estimated. ABR may also be used as a screening measure in older children but often requires sedation if the child is unable to be still for a prolonged period of time. Ambient noise, muscle artifact, and other neurologic involvement can interfere with the accuracy of ABR measurements. Conductive hearing loss results in present but delayed waveform responses.

Otoacoustic Emissions The development of OAEs represents one of the most significant technological advancements affecting hearing screening technology. OAEs are not a test of hearing directly but rather a measure of the integrity of the outer hair cells of the cochlea. An auditory stimulus is presented to the external ear via a probe inserted into the ear canal. A microphone in the probe measures the “echo” that is produced from the ear in response to the sound. There are two ways of eliciting OAE responses, transient evoked (TEOAE) and distortion product (DPOAE). A TEOAE utilizes a brief pulse of sound, such as a broadband click or tone burst and measures the resulting response during the quiet period between each presentation. With DPOAE, two continuous tones of different frequencies are presented simultaneously, which result in an emission that is a distorted copy and, hence, new frequency of the sounds presented. Through signal analysis, the distortion product is analyzed. The responses for both TEOAEs and DPOAEs are relative to the noise floor so that excessive background noise, heavy breathing, or other internally produced noises can make detection of some responses difficult. Both types of measurements are frequency specific: TEOAEs in the frequency range of 500 to 5000 Hz and DPOAEs in the 1000 to 8000 Hz range (Gorga et al., 1993; Probst, LounsburyMartin, Martin, & Coats, 1987). While OAEs cannot be used to predict hearing thresholds, TEOAEs generally detect hearing loss at levels of 30 dB  HL or greater, while DPOAEs are reported to detect hearing loss of 40 dB HL or greater (Gorga et al., 1993; Probst et al., 1987). Abnormal middle ear conditions usually result in absent OAEs. Careful interpretation of OAE results is necessary so as not to mislead parents that hearing is entirely normal when passing responses are obtained; for example, OAEs are generally present with auditory neuropathy/dyssynchrony spectrum disorder (ANSD), although they may disappear over time.

Chapter 4

in screening protocols are summarized in Table 4–6. They include the following:

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Chapter 4

Chapter 4

Generally, OAEs are quick, simple to conduct, and do not require a sound booth. Although cost may be a detractor for some, the utility of this procedure easily justifies the expenditure when pure-tone screening is not a viable option. The automated versions of each technology indicate whether the OAE response reached the pass criterion. Automated OAEs are frequently used for newborn screening because of the reduced disposable cost when eliminating the AABR electrodes and ear cuffs. There has also been an increase in the use of OAEs in early childhood and school screenings. As a procedure, OAEs have increased the effectiveness of screening programs for young children and other children who cannot respond to traditional play conditioning or pure-tone screening methods. With this technology, every child can be screened unless there are mitigating circumstances present. According to Hoffman, Shisler, and Eiserman (2011), a successful OAE screening program for young children involves well-designed equipment, disposable foam probe tips, and an easy to understand display for screening results. OAE screening is particularly useful in pediatric and school screening programs because it can screen both middle ear and inner ear function as a single procedure (though a refer then requires tympanometry to identify middle ear etiology). The Early Childhood Hearing Outreach (ECHO) initiative provides a guidebook for OAE screening, Early Childhood Hearing Screening & Follow-Up, Implementing a Successful Otoacoustic Emissions (OAE) Hearing Screening Program, An Audiologist’s & Facilitator’s Training and Technical Assistance Guide (https://www.infanthear ing.org/earlychildhood/docs/Audiologists-Guide.pdf).

Pure-Tone Audiometry Pure-tone screening is a quick procedure; the screening can be easily done by a trained volunteer or paraprofessional, and the test can be completed by most children with relative ease. Assuming that the number of frequencies screened, typically four, is sufficient, pure-tone screening is effective in identifying students who might have a peripheral hearing loss in one or both ears. It is not, however, possible to identify hearing losses that are milder than the screening level used. Because of the limitations imposed by noise levels in the environment in which screenings often occur, pure-tone screenings frequently use screening levels that are higher

Nuggets from the Field When conducting OAE screening with young children, play video cartoons without sound on an iPad or video monitor to focus their attention away from the procedure.

Plural_Johnson_Ch04.indd 90

FIGURE 4–1  Creare’s newly developed wireless automated hearing test system provides ambient noise attenuation sufficient for threshold testing outside the sound booth. (Photo courtesy of Creare, LLC.)

than would be ideal for the identification of mild hearing losses. Advancements in wireless pure-tone screening technology, such as Creare’s automated hearing test system (Figure 4–1), will reduce background noise issues and increase screening efficiency using automated protocols that provide flexible programming for various populations as well as thresholds options to 0 dB HL. Although Internetbased hearing screening programs are evolving, there are management issues that must be addressed to have an effective and reliable program. Conditioned play audiometry (CPA) is a very effective pure-tone technique with children between about 2/2.5 and 4 years of age or other children with developmental disabilities. The procedure requires no specialized equipment and because of the variety of play tasks that can be used children rarely habituate to the task. Training, to condition the child for the task, can be accomplished by using the earphone as a speaker and presenting the signal at a loudness level that is easily heard. For children who object to wearing standard or insert earphones, the earphones may need to be handheld. In this case, the modification needs to be noted because results may not represent true hearing sensitivity due to the altered calibration effect. When this situation occurs, the CPA must be supplemented with a physiological procedure such as OAEs. Table 4–6 summarizes the AAA (2011) recommended procedures and referral criteria screening.

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91

Hearing Screening and Identification TABLE 4–6  Summary of Pediatric Hearing Screening Procedures Target Population

Advantages

High Risk Indicator Checklist

Birth to 2 years

■■ ■■

Quick and easy to administer Identifies infants who require monitoring of hearing sensitivity due to presence of risk factors

Limitations ■■

■■

■■

Auditory Developmental Checklist

Birth to 3 years; other difficult to assess populations

History

All ages

■■

Visual Inspection of the Ear/Otoscopy

All ages

■■

■■ ■■

■■ ■■

Auditory Brainstem Response (ABR) ■■ Click ABR ■■ Tone Burst ABR ■■ Bone Conduction ABR

Newborns, infants, and toddlers, difficult to assess populations

■■

■■ ■■ ■■ ■■

Quick and easy to administer Provides functional data about child’s use of hearing and listening skills Identifies medical, familial, and other developmental information that may impact hearing ability Identifies visible structural abnormalities, ear canal drainage Requires minimal training Otoscopy additionally identifies conditions present in the ear canal and eardrum Identifies hearing losses greater than 30 dB HL primarily above 1000 Hz Predicts hearing thresholds Ear specific No behavioral response required Automated units require minimal training to use

■■

■■

■■

■■

■■

■■

■■ ■■ ■■ ■■

■■

Otoacoustic Emissions (OAEs)

Newborns, infants, and toddlers, difficult to assess populations

■■

■■ ■■

■■

■■

■■ ■■ ■■

■■

Identifies losses greater than 30 dB HL (TEOAE) or 40 dB HL (DPOAE) Noninvasive, simple procedure Does not require a very quiet environment Quick and easy to administer with most children Minimal cooperation required—does not require sedation Frequency specific Ear specific Useful with neurologically compromised Automated units require minimal training to use

■■

■■ ■■

■■

Requires audiological screening to identify hearing loss Cannot be used as a singular screening tool; 50% of cases of hearing loss may be missed Tracking may be difficult to assure that follow-up screening occurs Cannot be used as a singular screening tool; does not correlate with actual hearing sensitivity Cannot be used as a singular screening tool; does not determine hearing sensitivity Cannot be used to determine hearing sensitivity Otoscopy requires additional training and an otoscope usually limited to nurses and audiologists Requires quiet or sleeping infant or child; sedation often necessary for children who cannot sit still for long periods of time May miss mild and low-frequency hearing losses Equipment is expensive Interpretation complex Not frequency specific Difficult to interpret if central nervous system pathology present Measures only to brainstem

Chapter 4

Procedure

Valid screening difficult prior to 24 hours of age Measures only to cochlea Compromised by middle ear or outer ear involvement Cannot predict hearing thresholds

(Continues)

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92

Chapter 4

TABLE 4–6  (Continued ) Procedure

Target Population

Advantages

Pure-Tone Audiometry

2.5 years to adult

■■

■■

■■ ■■

Tympanometry

6 months or older

■■ ■■

■■ ■■

Behavioral Observation (Note: this procedure should no longer be considered a screening method except in very unique circumstances)

3 months to 2 years; special populations

■■

■■ ■■

Limitations

Identifies children who require further assessment Quick and easy to administer with developmentally appropriate ages Inexpensive Results are generally reliable Valid indicator of middle ear function Automated units are quick and easy to administer with most children Minimal cooperation required Equipment is relatively inexpensive Provides functional data about child’s use of hearing May provide ear-specific information May provide frequency-specific information depending on stimulus used

■■

■■

■■

■■ ■■

■■ ■■

■■

■■

■■

Chapter 4

Tympanometry Most audiologists recognize the importance of utilizing tympanometry with young children and at-risk populations. However, despite accurate and reliable equipment, a continued high incidence of middle ear disease, and continued recognition of the negative effects on learning that can occur from long-standing otitis media, tympanometry screening remains controversial. Many factors may have contributed to this problem, including a procedure that was more sensitive to tympanic membrane abnormalities than many physicians were able to diagnosis, referral criteria that were not well developed or validated, controversy among physicians regarding treatment, and lack of consistent follow-up guidelines. Further questions existed as to the purpose of tympano­ metry among school populations relative to identifying children who may have a medical condition requiring medical treatment versus an educational condition interfering with learning. The scheduling and follow-up protocols for tympano­ metry can also be challenging. It is difficult to know when and how often to perform tympanometry. If the screening is scheduled during the winter months when the incidence of middle ear problems is greatest, the refer rate will be higher than if the screening is done at another time of the year. Likewise, because middle ear problems are transitory in nature, the fact that children pass a screening does not mean they are clear of middle ear diseases at another point

Plural_Johnson_Ch04.indd 92

May not be valid with children who have developmental problems Requires some training to conduct procedure Requires very quiet environment Does not assess hearing sensitivity Follow-up protocols are variable

Requires a defined protocol Requires some degree of child’s cooperation Requires experienced audiologist to administer Generally requires a sound booth or specially designed equipment Needs confirmation from another test procedure to corroborate pass/refer status

in time. It may be necessary to use repeated screenings to identify all children with chronic middle ear disorders. It is difficult to determine the most effective screening protocol, but the potential harmful effects of chronic middle ear disease on learning make it critical that tympanometry be routinely provided for infants, toddlers, and preschoolers, either to accompany pure-tone screening or as a second-tier screening with OAEs. Pass and refer criteria must be estab­ lished with consideration of the age and risk factors of the target population and with consideration of national and lo­ cal medical treatment recommendations and philosophies. Professional guidelines should be consulted when developing these procedures. Recommendations for screening for abnormal middle ear status are included in the AAA Clinical Practice Guidelines: Childhood Hearing Screening (2011) and are included in Table 4–7. Acoustic immittance measurements have historically consisted of three procedures: tympanometric peak pressure, static admittance, and the acoustic reflex. Current screening for middle ear disorders consists primarily of tympanometric width measured in decaPascals at half of the height of the tympanogram (peak to the tail), and static admittance or size of the peak of the tympanogram. Consideration should also be given to canal volume in the interpretation (e.g., when pressure-equalizing tubes are present). Acoustic reflex measures are not used in screening procedures.

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Hearing Screening and Identification

93

TABLE 4–7  Summary of American Academy of Audiology Screening Procedures and Referral Criteria Age/Group Preschool and school-age children (preschool, kindergarten, grades 1, 3, 5, 7, or 9)

Preschool, kindergarten, grade 1

Screening Procedures ■■ ■■

■■ ■■

Preschool and school-age children for whom pure-tone screening is not developmentally appropriate (ability levels 250 daPa tympanometric width; rescreen within 8 to 10 weeks if passed pure tones

OAEs (primary DPAOE levels at 65/55 dB SPL)

Referral based on automated OAE’s preset cut-off values; rescreen with tympanometry

Note. AAA Clinical Practice Guidelines: Childhood Hearing Screening (2011).

Behavioral observation is not recommended as a screening technique except in unique circumstances where there are no other screening options. The conditions (equipment, environment, tester qualifications) under which these procedures need to be conducted render them inappropriate as screening measures. Conditioned play audiometry (CPA) and visual re­ inforcement audiometry (VRA) are procedures most often used with children and do, however, remain components of the audiological assessment battery. As such, they are discussed in Chapter 5, Assessment.

SCREENING AND IDENTIFICATION PROTOCOLS The purpose of a protocol is to utilize a set of procedures that will ensure the intended outcome. Protocols, therefore, must be designed specifically for each of the populations for whom they are intended so that sensitivity and specificity considerations are maximized. To ensure the integrity of the screening and identification program, it is critical that audiologists are involved in their development and management. Screening and identification protocol development must address the following: ■■

■■ ■■ ■■

■■

age or developmental considerations that affect the ability to participate in specific procedures; hearing conditions that are age specific; referral criteria; follow-up components to assure those referred receive the intended care; and parent notification and/or permission.

The following discussion will present screening issues and suggested protocols for infants and young children,

Plural_Johnson_Ch04.indd 93

school-age children, and children with developmental disabilities. Newborn protocols are not specifically addressed here. Personnel, screening environment, and other organizational and management considerations are discussed separately from the protocols.

Infants and Young Children Though most infants born in the United States now have access to hearing screening as a newborn, there must continue to be screening programs for infants and toddlers to monitor those with identified risk conditions, those who may not have received follow-up assessment, and those who may not have been screened at birth. Since population-based screenings do not exist for most infants and young children following the newborn period, physician’s offices, health departments (EPSDT), Early Head Start, Head Start, community-based programs such as ECHO and PAT mentioned previously, and local Child Find screenings, and public-school preschool programs provide the most common options for screening. Table 4–8 summarizes the four components of a hearing screening protocol for infants and young children through age 4 years. Infants and young children at risk for hearing loss due to factors associated with the birth, genetic history, or other conditions should also be monitored through this process.

Chapter 4

Behavioral Observation

School-Age Children and Youth Most public school programs have traditionally provided some level of vision and hearing screening for its students (see list of state statutes in Appendix 4–A). Because public education remains the first opportunity to have access to a large population of children, school entry at kindergarten or first grade has been the most common time to conduct population-based screenings after the newborn period.

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94

Chapter 4

TABLE 4–8  Suggested Hearing Screening Protocol: Infants and Young Children 6 Months Through 4 Years Referral Criteria Considerations1

Screening Components

Procedural Recommendations

History

Ask for information regarding the following: ■■ Family history of hearing loss ■■ Problems during pregnancy or delivery ■■ Number of episodes of ear infections, tubes, or other ear surgeries ■■ Parental concerns ■■ Speech/language development ■■ Other developmental concerns ■■ Previous hearing tests, including newborn screening

Visual Inspection

Look for: ■■ Structural defects ■■ Drainage from the ear canal ■■ If using otoscopy, look for ear canal and tympanic membrane abnormalities

Hearing Sensitivity

■■

■■

Tympanometry

■■

■■

Automated OAE or if child can reliably perform play audiometry Conduct pure-tone audiometric screen at 20 dB HL at 1000, 2000, and 4000 Hz

Chapter 4

Conduct when: ■■ Automated OAE procedure is abnormal (e.g., “refer”) ■■ Audiometry is performed

■■

■■

■■

■■

Use information to inform screening and followup process; if family history of hearing loss, monitor twice/year until school age

Refer for medical attention if ear drainage is observed; any other concerns should be noted but not used to refer for medical attention and/ or audiological attention if otoacoustic emissions (OAEs) or pure tones and tympanometry screenings are passed OAE: if OAE screening is not passed follow with tympanometry Play audiometry: refer if any signal presentations are not passed at frequency and decibel levels indicated and tympanometry is normal Rescreen in 6 to 8 weeks if  TW >250 daPa; if child has tympanostomy tubes, refer if equivalent ear canal volume ] 

Test Technique: ❑ COR (Conditioned Response) ❑ CPA (Play Audiometry) ❑ Traditional ❑ Sound Field ❑ Headphones ❑ Insert Earphones Test Reliability: ❑ Good ❑ Average ❑ Poor Audiometer: ________________________

60

100

 n < [ 

Chapter 5

RIGHT EAR

Air Air Masked Bone Bone Masked No Response Unaided Sound Field FM System Narrow Band Warble Tone Did Not Test Within Normal Limits Speech Reception Threshold Speech Awareness Threshold Pure Tone Average High Frequency Average (2,4,6K)

Left

KEY

HISTORY Reason for referral_________________________________________________________________________ ❑ No significant health history reported ❑ Birth history ❑ Newborn hearing screening: Pass__ Refer __ ❑ Family history of hearing loss ❑ Ear infections ❑ Speech/language concerns ❑ Noise exposure ❑ Previous testing _______________________ ❑ Other________________________________________

Right

DATE OF BIRTH:_____________ GRADE:_____ ID#:_________ SEX: M / F AUDIOLOGIST: __________________

 Left

Ear/Condition % % % % %

Score dBHL dBHL dBHL dBHL dBHL

List LV Rec LV Rec LV Rec LV Rec LV Rec

Comments: _________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ IMPORTANT: Please see attached Audiologic Assessment Page 2 for interpretation and recommendations.

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140

Chapter 5 Assessment

School District/Co-op/Agency Name EDUCATIONAL AUDIOLOGY

Insert your logo here

Phone/FAX/web/email

AUDIOLOGIC ASSESSMENT (Page 2) NAME:_________________________________SCHOOL:_________________________DATE OF ASSESSMENT:_____________ IMMITTANCE RESULTS

ASSESSMENT RESULTS (non-amplified) Right ❑ ❑ ❑ ❑ ❑ ❑

Left ❑ ❑ ❑ ❑ ❑ ❑

Right ❑ ❑ ❑ ❑

Left ❑ ❑ ❑ ❑

SF* ❑ ❑ ❑ ❑ ❑ ❑

Degree of Hearing Loss Normal Borderline Mild Moderate Severe Profound

Type of Hearing Loss Conductive Sensorineural Mixed Auditory Neuropathy/Dys-synchrony

* Sound Field: a difference between ears cannot be ruled out.

Hearing Loss is: ❑ Unilateral (one ear) __Right __Left ❑ Bilateral (both ears) ❑ High Frequency

Right Left ❑ ❑ ❑



Essentially normal middle ear function. Possible middle ear problem.

h Type B tympanogram(s) consistent

with non-mobile eardrums(flat)

HEARING INSTRUMENTS Right Left ❑ ❑ Hearing aid(s) is functioning appropriately and providing benefit to meet amplification goals. ❑ ❑ Hearing aid is not functioning appropriately and / or not providing adequate benefit. Hearing Assistance Technology (HAT): Functioning as intended and meeting goals for HAT? Yes ❑ No ❑ Comments:_____ _______________________________

SPEECH PERCEPTION Comments:

_____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________

EDUCATIONAL IMPLICATIONS

Chapter 5

❑ Hearing is adequate for educational purposes (e.g., communication and learning) at this time; no accommodations needed. ❑ Hearing loss may impact communication skills as well as access and participation in daily life functions; some accommodations may be needed (see recommendations). ❑ Hearing loss is educationally significant and impacts communication and learning; accommodations needed (see recs below). ❑ Fluctuating hearing loss from recurrent middle ear problems may impact listening and learning; accommodations may be needed. ❑ Hearing ability has not significantly changed since previous testing dated_____________________________. RECOMMENDATIONS (Please refer to marked items only) ❑ There are no further recommendations at this time. ❑ Today’s test results suggest that the parent/guardian should arrange an appointment with physician / ear specialist / private audiologist. Comment:________________________________________ _________________________________________________ ❑ A follow-up audiologic assessment should take place following medical evaluation and treatment. Please call ______________to schedule this appointment. ❑ An annual audiologic assessment needs to be administered by the Educational Audiologist in order to monitor this student’s hearing. ❑ Due to this educationally significant hearing loss, it is recommended that an Auditory Skills Assessment and/or additional follow-up at this student’s school be completed by the Educational Audiologist, with further recommendations to follow. ❑ To maximize benefit for this student, it is recommended that communication between home, school, medical and private service providers be maintained. ❑ Please see attached handout(s) for further accommodations and modifications which may be of benefit for this student based on today’s test results.

❑ This student will benefit from special, flexible seating in all academic settings. ❑ This student’s educational programming (IEP) should reflect appropriate accommodations and modifications for his/her hearing loss, and should be based on the student’s identified communication and other needs as determined by the IEP team. This student may require support services and/or assistive technologies to enhance access to auditory information in the classroom. ❑ This student will benefit from continued use of personal hearing instruments provided by the parent/guardian. ❑ This student will benefit from continued use of hearing assistance technology provided by the school district to improve access to auditory information in the educational setting. ❑ Test results today suggest that this student should avoid exposure to high noise levels (i.e. loud music, machinery) or wear ear protection to protect ears from further hearing loss. ❑ Other recommendation(s):________________________________ ___________________________________________________________ ___________________________________________________________ ___________________________________________________________

If there are questions regarding this report, or if I can be of further service on behalf of this student, please do not hesitate to contact me. __________________________________ Educational Audiologist

Source: Adapted from Audiology Assessment, Educational Audiology Services, Denver Public Schools

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Assessment

141

The New Count-the-Dot Audiogram1 by Killion & Mueller: the Hearing Journal January 2010 vol 63 No 1 page 10. Name

Date of birth

School

Grade

Completed By

AI of ____ dots = ____%

-10

125Hz

250Hz

Sound Frequencies in Hz 500Hz 1kHz 2kHz

4kHz

8kHz

0 10 20

Hearing Level in dBHL

30 40 50 60 70

This is the Speech Intelligibility Index (SII) based method of calculating the Articulation Index (AI). There are 100 dots indicating the importance of different frequencies and intensities for the perception of speech. Instead of the technically correct ‘audible speech cues weighted by the importance function at each frequency’, the authors recommend calling them ‘audible dots’. This supersedes the first black and white (and grey) count-thedot PTA from 1990 and has more dots above 4kHz now, acknowledging findings of more recent research. There is no copyright on this format (by original authors or Peter Keen) so that people can use it! How to use it: Put the thresholds for both ears onto the Audiogram as normal. Count the dots below the (straight) lines joining the O and X symbols (use the better ear for each frequency). For Aided thresholds, add these to the audiogram using the A symbol, then count the audible dots. All thresholds must be in dBHL, so Aided results using a sound level meter must be converted – see chart below. The total ‘audible dots’ represent the percentage Articulation Index, so 65 audible dots = an AI of 65%. For children who are still developing their phonology and acquiring speech and language, Peter Keen recommends:

Good: Satisfactory: Concern:

Chapter 5

80

AI of 90% to 100% AI of 70% to 89% AI of 69% or less

Conversion chart: dBA (Sound Field, sound level meter reading) to dBHL. System developed by Dr Mike Nolan Frequency 250Hz 500Hz 1kHz 2kHz 3kHz 4kHz 6kHz 8kHz -17 -8 -10 -10 -11 -10 -15 -12 e.g. at 500Hz: 55dBA - 8dB converts to 47dBHL 1Form

devised (Jun 2014) by Peter Keen, Consultant Educational Audiologist, Keenhearing: [email protected]. Adapted with author permission.

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APPENDIX

5–D Word Recognition in Quiet and Noise for Normally Developing Children

BODKIN, K., MADELL, J., & ROSENFELD, R. AMERICAN ACADEMY OF AUDIOLOGY CONVENTION, 1999, MIAMI, FLORIDA—POSTER SESSION Summary: ■■ ■■

■■

■■

■■

■■

Subjects: 126 “normal” children (i.e., hearing, ME function, development), ages 3 to 17 years Purpose: to obtain age-appropriate normative data in a variety of listening situations and to evaluate a practical means of speech-in-noise (SIN) testing suitable for routine clinical evaluations, not just research studies Method: testing conducted at normal and soft conversational levels in quiet and at two competing noise levels using age-appropriate word recognition tests; competing signal was four-talker speech babble Stimuli: …… CA 3–4: NU-CHIPS (open set) …… CA 5–6: PBKs …… CA 7+: W-22s Findings: word recognition scores did not decrease significantly as the listening task became more difficult, regardless of age Benefit: procedure may be a useful diagnostic tool to differentiate between children with normal and abnormal auditory function

Chapter 5 Note. CI, confidence interval; SD, standard deviation. From Bodkin, K., Madell, J., & Rosenfeld, R. (1999). Reprinted with permission.

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5–E SPEECH AUDIBILITY AUDIOGRAM FOR CLASSROOM LISTENING

Student

Grade 250

Loudness in dB HL

0

10

15

20

25

30

35

40

500

School 1000

Date 2000

Soft speech (35 dB HL)

4000

8000 Hz

Teacher voice (50 dB HL)

Typical hearing children: 93-98% word recognition in quiet 86-94% at 35 dB HL in 0 S/N noise.1

Typical hearing children: 92-100% word recognition at 50 dB HL in quiet, 90-97% in +5 S/N, and 89-96% in 0 S/N noise.1

95% audibility of speech energy perceived with hearing levels between 0 – 10 dB HL

0-20 dB HL should perceive 98% of speech sounds at a comfortable level in a quiet classroom and acceptable reverberation levels (35 dBA or less background noise in an unoccupied classroom & reverberation no greater than 0.9 sec3)

64% at +10 S/N, 34% at 0 S/N2 75% audibility of speech energy perceived with hearing levels between 10 – 15 dB HL

84% at +10 S/N, 48% at 0 S/N

44% at +10 S/N, 24% at 0 S/N 60% audibility of speech energy perceived with hearing levels between 15 – 20 dB HL 29% at +10 S/N, 9% at 0 S/N 40% audibility of speech energy perceived with hearing levels between 20 – 25 dB HL

95% audibility of speech energy perceived with hearing levels between 20 – 25 dB HL

9% at +10 S/N, 0% at 0 S/N

81% at +10 S/N, 55% at 0 S/N

25% audibility of speech energy perceived with hearing levels between 25 – 30 dB HL

81% audibility of speech energy perceived with hearing levels between 25-30 dB HL

0% in any setting that is not quiet

67% at +10 S/N, 41% at 0 S/N

15% audibility of speech energy perceived with hearing levels between 30 – 35 dB HL

60% audibility of speech energy perceived with hearing levels between 30-35 dB HL

0% in any setting that is not quiet

46% at +10 S/N, 20% at 0 S/N

10% audibility of speech energy perceived with hearing levels between 35 – 40 dB HL

45% audibility of speech energy perceived with hearing levels between 35 – 40 dB HL

0% in any setting that is not quiet

31% at +10 S/N, 5% at 0 S/N 30% audibility of speech energy perceived with hearing levels between 40 - 45dB HL

Hearing with amplification

45

Chapter 5

Permission is granted to individuals who have purchased this form to reproduce or electronically share it only to serve their specific students. Sharing this content in any manner not related to a specific student’ s education is prohibited.

APPENDIX

Hearing without amplification

16% at +10 S/N, 0% at 0 S/N

S/N means the loudness of the speaker’s voice (i.e. teacher) over the background noise. 0 S/N = noise and voice are the same loudness. FM negates the affects of background noise and distance and provides optimal access to verbal instruction in large and small groups.

Results of Functional Listening Evaluation4: Type of speech materials used: SPEECH PERCEPTION

Close / Quiet

Close / Noise

Distant/Quiet

Distant/Noise

Loudness:

Close =

dB Feet

Distant =

Feet

Auditory + Visual

Quiet =

S/N*

Auditory Only

Noise = S/N* *at child’s ear level

Audibility represents the listening challenge, or fragmented speech perception, experienced by listeners with hearing loss. Audibility should not be interpreted as speech perception.

AUDIBILITY

Quiet

No noise

+10 dB S/N

0 dB S/N

Good classroom Very noisy listening condition classroom listening condition

Recommended Hearing Technology/ Accommodations:

Estimated Audibility Soft Speech Estimated Audibility Teacher’s Speech 1. 2. 3. 4.

Bodkin, K, Madell, J., & Rosenfeld, R. (1999). Word recognition in quiet and noise for normally developing children, AAA Convention, Miami, Poster Session. Nelson, P. Anderson, E., Nie, Y., Katare, B. (2010). Effect of reduced audibility on masking release for normal- and hard-of-hearing listeners, JASA 127, 1903 Yang, W., & Bradley, J. S. (2009). Effects of room acoustics on the intelligibility of speech in classrooms for young children. J. Acous. Soc. Am., 125(2), 922-933. Revised 2004 by Johnson. Based on Functional Listening Evaluation by C.D. Johnson & P. Von Almen, 1993.

Karen L. Anderson, PhD, 2011 www.kandersonaudconsulting.com © 2011 Karen Anderson and Kathy Arnoldi From Building Skills for Success in the Fast-Paced Classroom, page 132, Butte Publications.

Note. From Karen Anderson and Kathy Arnoldi. (2011). Building Skills for Success in the Fast-Paced Classroom. Retrieved from http://success forkidswithhearingloss.com Reprinted with permission.

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5–F

APPENDIX

Adaptations for Assessing Children/Youth Who Are Blind/Visually Impaired General Considerations Prior to Testing ■■

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Consider relationship of vision impairment to Usher syndrome as a possible etiology Review functional vision assessment (completed by a certified teacher of the visually impaired) Review visual assessment for information about distance and visual field abilities If child has additional disabilities, check for specific likes/dislikes, reinforcers, and behavioral characteristics with the special education teacher

Test Procedures ■■

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Test Preparation ■■ ■■

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Chapter 5

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Remove physical obstacles in test area Determine appropriate adaptations based upon child’s visual field, distance vision, color, and light abilities If child is not familiar with your voice, introduce yourself by name Allow extra testing time to accommodate modifications that may have to be made in assessment procedures If partially sighted: …… Obtain large clear pictures (nonglare and without visual clutter) …… Regulate the lighting (indirect light from the child’s back is best) …… Adjust VRA equipment according to the child’s light sensitivity and perception by darkening the sound booth (inside and out) and pairing the auditory stimulus with a bright red light (for some children bright white light may be aversive) that is turned on from outside the booth; condition the child to turn to the light every time he or she hears the sound …… Eliminate glare of tester window; if necessary, position child with back to the window using a mirror to track the child’s expressions and be cognizant of their visual field Provide the child detailed descriptions of the environment and what is happening at all times Incorporate more tactile contact and reinforcements (rubbing back, patting arm, etc.) Alert child verbally prior to touching or providing tactile orientation

■■

■■

Observe localization abilities for speech as well as warble tones; responses may be subtle such as eyewidening, quiets, ear pointing, or head tilt Pure-tone threshold audiometry …… Use tactile cues during training of conditioned play response (e.g., pair the auditory stimulus with a tactile stimulus by having the child hold the bone conduction oscillator [condition using a low frequency stimulus as it is easier to feel]) …… When necessary, shape the child’s response through physical guidance as part of the instructional process (e.g., physically guide child’s hand to achieve the desired response) …… Use a tin bucket with objects that are easy to grasp and release (e.g., blocks, ping pong balls) to create a noise when responding to sound …… If the TROCA (tangible reinforcement operant conditioning audiometry) method is necessary, orient the child to the reinforcers prior to testing …… Instruct child to point to his/her ear when the “birdie sound” is heard Demonstrate speech understanding through one of the following methods based on the child’s language and cognitive ability: …… Point to/touch body parts …… Repeat spondee words (bisyllabic words with equal stress); when using spondees, think about words that are easily distinguishable for the child who is blind/ visually impaired (e.g., pinwheel, popcorn, cupcake, hot dog, jump rope) …… Repeat familiar words …… If pictures can be used for closed-set test measures obtain ones that are high contrast, clear, and noncluttered …… Play “find the toy”—put familiar objects in a basket that the child can pick out when named; make sure they have different textures and shapes and that the child is familiar with them first When conducting speech-in-noise testing, orient the child to the task by explaining and describing background noise and the primary voice the child should listen to; acclimate the child by introducing the background noise gradually as children who are blind/

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■■

■■

Use electrophysiological tests (auditory brainstem response [ABR], otoacoustics emissions [OAEs]) to supplement behavioral measures

Follow-Up and Accommodations ■■

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■■ ■■

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Refer to state deaf blind project if combined vision and hearing loss are present Refer for medical care when necessary (e.g., frequent otitis media) Monitor hearing status with routine hearing screening Emphasize the need for an acoustically appropriate learning environment and provide accommodations when necessary Consider hearing assistance technology on an individual basis depending on the functional abilities of the child, the child’s learning environment, and the child’s communication needs

Chapter 5

■■

visually impaired may be hypersensitive to noise in addition to being unfamiliar with the setting; …… Use linguistically appropriate material at various intensity levels (+30 dB SL to obtain maximum performance; +10 dB SL for understanding quiet speech, 65 dB SPL for typical conversation level, and at a speech-to-noise ratio of zero for adverse listening condition) …… Output determination for speech and noise testing is based on the sound booth speaker arrangement: with a two-speaker setup, speech and noise should be presented from the same speaker and located in front of the listener (0 azimuth); with multiple speakers, speech should be presented from the front speaker (0 azimuth) and noise from speakers at the right and left of the listener If the child’s behaviors to sound are difficult to interpret, include the teacher of the visually impaired in the test session to help with determination of responses; parent may also be able to assist Conduct a functional auditory assessment to identify how the child is using his/her hearing ability (required for federal reporting of children who are deaf blind)

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APPENDIX

5–G Common Functional Outcome Measures for Listening Performance

Instrument

Target Population

Description

Goal/Purpose

Ages 4–14

Parent/caregiver questionnaire consisting of 24 auditory behaviors that are organized into three categories: aural-oral, auditory awareness, and social/conversational skills.

To assess parental perceptions of their children’s auditory behaviors.

Children’s Home Inventory for Listening Difficulties (CHILD), Anderson & Smaldino (2000)

Ages 3–12

Parents/caregivers judge 15 situational listening behaviors using an 8-point scale on the “Understand-O-Meter.” An average score can be computed to compare ratings of different individuals, listening skill improvement over time, or amplification benefit. Children who are 7 to 8 years can be administered the inventory either through interview or by reading the questions themselves.

To assess perceptions of listening behavior and subsequent communication needs; may be used to determine current ability, monitor progress over time, or evaluate the benefits of amplification devices or other accommodations.

Children’s Auditory Performance Scale (CHAPS), Smoski, Brunt, & Tannahill (1998)

School age

Respondents judge the amount of listening difficulty experienced by a child on 36 items organized in six conditions and skills (noise, quiet, ideal, with multiple inputs, auditory memory sequencing, and auditory attention span) by comparison to other children in the same situation and of similar age and background. Average scores for each of the conditions as well as a total score place the child in “normal” or “at-risk” categories. Rating comparisons from difference sources (e.g., parent, classroom teacher, special education specialist) offer insight into difficulties that may be environmental or situational.

Initially designed as a screening tool to identify children who should be referred for a (central) auditory processing evaluation; also used to assess perceptions of situational listening behavior; may be used to determine current ability, compare perceptions of various respondents (parents, teachers), or determine the benefits of amplification devices or other accommodations.

Classroom Participation Questionnaire (CPQ), Antia, Sabers, & Stinson (2007)

School age

A self-assessment of communication and classroom participation skills using a 4-point rating scale on a 28-item (long) or 16-item (short) form. Items are asked randomly and then the interpretation is organized under four headings: Understanding teacher, Understanding students, Positive Affect, and Negative Affect. The self-assessment can be completed by most students age 7 years or older and may be read to nonreaders. T   he self-assessment serves as a counseling tool to assist students in solving classroom communication and participation issues including use of amplification and hearing assistive technology.

To assess classroom communication access and participation abilities; useful as a counseling tool to discuss solutions to communication problems and to validate the effectiveness of various amplification and assistive technology options.

Children’s Outcome Worksheets (COW), Williams (2004)

Ages 4–12

Checklist for child, parent, and teacher to identify and rate pre- and postfitting performance observed in 16 everyday situations.

To document change in hearing performance with hearing instruments.

Chapter 5

Auditory Behavior in Everyday Life (ABEL), Purdy et al. (2002)

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Instrument

Target Population

Description

Goal/Purpose

147

Developmental Index of Audition and Listening (DIAL), Palmer & Mormer (1999)

Infant through age 22

A functional auditory milestones checklist consisting of 14 skills arranged in a hierarchy according to the age group in which it is expected to emerge (from infant to age 22 years).

To determine the child’s current level of function and to assist in the development of goals for future milestones; may also be useful to guiding parental and child expectations.

Early Listening Function (ELF), Anderson (2002)

Infant to young child

Parents/caregivers observe their child during quiet, typical, and loud listening activities at various distances from 6 inches to 15+ feet/next room. Child’s response is judged as yes, maybe, or no. The audiologist or early interventionist scores the results using a weighted formula comparing responses at less than or greater than 6 feet.

To identify if a child is able to detect certain sounds from various distances in both quiet and noise; to increase parent involvement in analyzing their child’s listening behaviors, to estimate amplification benefit; to track improvements in auditory development over time.

Student/Pediatric Amplification Listening Evaluation, Johnson (in Gabbard, 2004)

Infant through school age

A brief validation tool for RM HAT use that compares performance in five areas (responds to name, attending to person speaking, distinguishes between words that sound alike, responds appropriately to spoken directions, and comprehends oral instruction and concepts) with and without RM HAT. Behavior is rated on a 5-point scale. Each of the five areas includes analysis in quiet, noise, distance, and auditory only situations. Additional questions address ease of use issues. There are two forms: one for infants and young children and one for school-age children.

To validate benefit of RM HAT use; may also be used to compare various types of RM HAT.

Functional Auditory Performance Indicators (FAPI), Stredler-Brown & Johnson (2004)

Infant through school age

Auditory skills are assessed in seven areas (awareness and meaning of sounds, auditory feedback and integration, localizing sound source, auditory discrimination, auditory comprehension, short-term auditory memory, linguistic auditory processing) in a variety of conditions (visual/ auditory versus auditory only, close versus distance, quiet versus noise, prompted versus spontaneous). Thirty-three skill areas are assessed through direct observation and/or parent report and judged by the respondent as “not present,”  “emerging,” or “acquired.” Using weighted scoring, a profile of the child’s functional auditory skills is generated. Though hierarchical in structure, it is expected that children are working on multiple skills from different categories in an integrated intervention program.

To assess and monitor progress of developing auditory skills within a comprehensive framework incorporating basic to higher-level linguistic skills; to identify goals for therapy and/or classroom instruction; the benefits of amplification may also be validated based on several of the conditional responses.

Functional Listening Evaluation (FLE), Johnson (2009)

Preschool through school age

Listening performance is assessed and compared in eight conditions (close-quiet, close-noise, close-auditory/visual, close-auditory only, distance-quiet, distance-noise, distance-auditoryvisual, distance-auditory only) using word, phrase, or sentence material. T   he assessment occurs in the child’s classroom in order to reflect the acoustical parameters of the child’s typical listening and learning environment. Conditions may be repeated to compare or validate the benefits of various amplification devices and arrangements. Scoring is based on percentage of correct responses or other analysis used depending on the stimulus material employed.

To provide evidence of listening abilities under the typical conditions encountered in a student’s customary learning environment; to validate the benefits of hearing assistance technology as directed by the functional evaluation requirements for assistive technology under IDEA.

Chapter 5

Assessment

(Continues)

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Instrument

Target Population

Description

Goal/Purpose

Chapter 5

Ling Six-Sound Test, Ling (1976)

Young children to adult

A simple, quick test to assess reception of six speech sounds that cover the frequency range of basic speech production: ah, oo, ee, sh, s, m. Basic detection (is the sound present or absent), identification (repeat the sound heard), and/or discrimination skills (are two sounds presented the same or different) can be assessed based on the auditory skill level of the child and the subsequent response requirements.

To assess a person’s ability to detect, identify, or discriminate six speech sounds that cover the speech frequency spectrum; used to verify basic hearing aid, cochlear implant, and FM function.

Listening Inventory for Education (L.I.F.E., Revised), Anderson, Smaldino, & Spangler (2011)

School age

A set of three questionnaires that assesses efficacy of amplification use. The Student Appraisal of Listening Difficulty contains 15 common classroom listening situations (five are optional) that the student rates on a 5-point scale to compare pre- and postamplification use. For nonreaders, photos that describe the situations may be used to assess the situations. The accompanying Teacher Appraisal of Listening Difficulty contains 16 questions that assess change in behavior or performance based on the use of amplification. A total appraisal score suggests the level of support for amplification use. The Teacher Opinion and Observation List contains four areas that allow teacher comments on the effects of amplification intervention in the classroom. Suggestions for improving classroom listening are included that are helpful counseling tools for both students and teachers.

To provide evidence of benefit of amplification by students (selfreport) and teachers (observation); also beneficial as a training tool for implementing appropriate strategies and accommodations to enhance listening and communication in the classroom.

LittlEARS Auditory Questionnaire, KuehnInacker, Weichboldt, Tsiakpini, Coninx, & D’Haese (2003)

0–24 months

Parent/caregiver questionnaire of 35 simple “yes” or “no” questions regarding basic auditory behaviors. Examples are provided for each item.

To provide information regarding hearing aid benefit, cochlear implant candidacy, and postimplant evaluation of auditory skill development.

Meaningful Auditory Integration Scale (MAIS), Robbins, Renshaw, & Berry (1991) Infant Meaningful Auditory Integration Scale (IT-MAIS), Zimmerman-Phillips, Robbins, & Osberger (2000)

Preschool and school age

A parent report scale about how often a child demonstrates various auditory and speech skills that is administered in a structured interview format. The10 skills are grouped into three categories: vocalization, spontaneous alerting to sound, and deriving meaning from sound.  A scale of 0 to 4 rates the frequency of the target behavior and is compared to an average.

To determine the status of basic developing auditory skills in young children who are profoundly deaf in everyday situations before and after being fitted with hearing aids and/or receiving a cochlear implant.

Infant– Toddler

(Continues)

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Instrument

Target Population

Parent’s Evaluation of Auditory/Oral Performance of Children (PEACH)Teacher’s Evaluation of Auditory/Oral Performance of Children (TEACH), Ching & Hill (2007)

Description

Goal/Purpose

Parent/caregiver and teacher questionnaires for assessing the effectiveness of amplification. PEACH and TEACH utilize a structured interview technique to avoid biased responses and strict criteria for scoring to increase reliability. Each questionnaire lists a number of probe areas, then gives the specific question(s) that are to be asked by the interviewer. For each probe area, additional questions that might be applicable to behavior of young children are also given. The interviewer records the parents’ answer in its entirety and is instructed to ask for specific examples of when and where the parents or teacher has observed the behaviors and record all examples. Scoring is based on the proportion of time a child demonstrates a certain behavior, or the number of examples that parents or teachers provide regarding a child’s performance in different situations.

To assess the effectiveness of amplification for children based on a systematic use of parents’ and teachers’ observations, respectively.

Preschool Screening Instrument for Targeting Educational Risk (PRE-school SIFTER), Anderson & Matkin (1996)

Preschool

Teacher questionnaire rating 15 skills that are organized under the categories of Pre-academics, Attention, Communication, Class Participation, and Social Behavior. Ratings are determined in comparison to classroom peers. Using a 5-point rating scale, the sum of scores for each category places the child in ranges of “pass” and “at-risk.”

A screening tool to identify preschool-age children at risk for developmental or educational problems due to hearing loss who need further investigation and possibly referral to special education.

Screening Instrument for Targeting Educational Risk (SIFTER), Anderson (1989)

School age

Teacher questionnaire rating 15 skills that are organized under the categories of Academics, Attention, Communication, Class Participation, and Social Behavior. Ratings are determined in comparison to classroom peers. Using a 5-point rating scale, the sum of scores for each category places the child in ranges of  “pass” and “marginal” or “fail.”

A screening tool to identify children at risk for developmental or educational problems due to hearing loss who need further investigation and possibly referral to special education.

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Assessment

Note. Adapted from L. Klop (2005) by Cheryl DeConde Johnson.

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APPENDIX

5–H The Functional Listening Evaluation

Purpose of the Functional Listening Evaluation (FLE) The purpose of the FLE is to determine how listening abilities are affected by noise, distance, and visual access in a student’s everyday listening environment. The FLE can also be used as a validation tool to demonstrate the benefits of hearing assistance technology. It is designed to simulate listening ability in situations that are representative of typical classrooms and other settings that cannot readily be replicated in sound booth assessment. Through observation of the administration of the evaluation, the student’s teachers, parents, and others may gain appreciation of the effects of adverse listening conditions encountered by the student. When comparing performance without and with the addition of hearing assistance technology such as an FM system, the evaluation results provide evidence of the benefits of the device in enhancing access to the desired input. The format of the FLE may also be useful in justifying other accommodations, such as sign language or oral interpreting, note-taking, captioning, special seating, and room acoustic modifications. This protocol is based on a listening paradigm suggested by Ying (1990), and by Ross, Bracken, and Maxon (1992).

the size, ambient noise level, and floor and wall surfaces of the student’s classroom. While performance during actual class sessions would seem ideal, the test process itself may be disruptive to instruction for the rest of the class and therefore may not reflect the true listening conditions encountered by the student throughout the day.

Physical Set-Up of Test Environment Due to room size and instructional style variations, the occupied classroom should be observed to determine maximum listening distances. Record this as the “far” distance on the Summary and Interpretation Form. When setting up for the close conditions, measure the 3 foot distance from the student’s ear to the examiner’s mouth. Close: Noise and examiner are 3 feet in front of the student (see Diagram A). Far: Noise remains 3 feet in front of the student; the examiner moves back to the pre-determined distance (12 to 15 feet in this example) from the student (see Diagram B).

Chapter 5

Materials Needed ■■

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CD player, iPad, iPod, or laptop computer to play noise source Sound Level Meter or SLM App - use A weighted scale Classroom noise source (.wav sound file or CD; classroom noise or multitalker is recommended) Word/Phrase/Sentence Lists for test stimuli Tape measure Acoustic Hoop

FIGURE 5H–1A  Diagram A. Close.

Environment for Testing The student’s classroom should be utilized during a time when students are not present. If the student has multiple classrooms choose the one where most speaking and listening instruction occurs or where there is concern regarding communication access. If one of the student’s classrooms is not available, choose a room that most closely approximates

FIGURE 5H–1B  Diagram B. Far.

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In order to simulate classroom listening ability, the speech evaluation material utilized should be developmentally appropriate and approximate material that is encountered by the student in the classroom. Additionally the stimuli should have sufficient length to reflect reverberation characteristics of the room. Consideration should also be given to both familiar and new material that a student may encounter. Individuals will usually perform better with familiar material than with stimuli containing unfamiliar vocabulary. Students with unilateral and mild hearing losses tend to perform well under all conditions due to the audibility and inherent redundancy in phrase and sentence material utilizing familiar vocabulary. Nonsense phrases have been constructed to increase listening difficulty. Age, language competency, and memory abilities of the individual should also be considered when determining the test stimuli. In selecting word, phrase or sentence materials, consider whether the vocabulary and syntax are appropriate for the student’s language level. For students with poor speech intelligibility, as well as young children, it may be necessary to use materials that incorporate picture-pointing responses. If closed-set materials are utilized, performance can be expected to be better than with open-set materials. Once the type of stimuli is determined, it must remain constant throughout the assessment so that the variables manipulated are noise, distance, and visual input. Report the material used on the Summary and Interpretation Form. Common materials include are listed below. In many of these materials there will not be sufficient lists for the entire protocol (8 lists are needed). If it is necessary to use a list twice, select the lists that were more difficult for the student in order to reduce familiarity with the material. The Common Children’s Phrases and the Children’s Nonsense Phrases each contain eight lists of twenty phrases and provide the option of phrase or word scoring. The Recorded Functional Listening Evaluation Using Sentences (Johnson & Anderson, 2013) is now available on CD from https://successforkidswithhearingloss.com. This version utilizes 5-word HINT-C (Hearing in Noise Test for

Sentence Materials: Phrase Materials: Word Lists: Picture – Closed Set:

Children) sentences that were based on the original BamfordKowal-Bench (BKB) sentences (1979). Half of the sentences are recorded in quiet and the other half with a +5 SNR (signal-to-noise ratio) and follow the condition presentation order of the FLE. This version simplifies presentation of the FLE by eliminating the need for a noise file and adjusting noise and speech sound levels; however the SNR cannot be altered. Additional instructions are provided with the CD.

Presentation Levels The conditions of close/far and auditory/auditory-visual are presented in quiet (4 presentations) and then in noise (4 presentations) to achieve the eight conditions. Speech-to-noise ratio levels (SNR) should be based upon the auditory environments encountered by the students in their classrooms. Sound level measurements of classroom discourse and activity may be necessary to determine these levels. For this example, the levels will achieve values resulting in a +5 dB speech advantage in the close conditions and a –5 dB speechto-noise ratio in the far conditions (12 to 15ft). Levels will vary slightly depending upon the acoustics of the room and consistency of the examiner’s voicing of the stimuli. Measure and record the classroom ambient noise level (unoccupied), approximate teacher or talker levels, and noise levels as directed on the scoring form. Speech: Calibrate the examiner’s voice at a distance of 3 feet from the listener (close condition). Ask the student to hold the SLM to their ear and the examiner to talk measuring the examiner’s voice with the sound level meter so that speech averages 65dBA SPL at the listener’s ear. Once that level is measured, check the SPL level when the sound level meter is held one foot from the examiner’s mouth (being careful to keep the voice level the same) so that the examiner can hold the sound level meter to monitor his/her voice for all conditions to verify that the proper speech level is maintained. The level at 1 foot from the examiner

BLAIR Sentences SPIN Sentences (older students) PSI Sentences Common Children’s Phrases PB-K WIPI

Chapter 5

Types of Evaluation Materials

151

WIPI Sentences BKB Sentences HINT-C Sentences Children’s Nonsense Phrases NU-6 NU-CHIPS

Note: The Common Children’s Phrases and Nonsense Phrases are available in the Educational Audiology Handbook (2nd ed.) (Johnson & Seaton, 2012) as well as the author’s website: http://www.ADEvantage.com; word and sentence lists should be available from most pediatric and educational audiologists.

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Assessment

will be approximately 3 dBA SPL greater that at the listener’s ear for close conditions). Noise: Locate the noise source 3 feet from the student and adjust the volume of the noise source (classroom/multitalker noise) using a sound level meter, so that the noise averages 60 dBA SPL at the student’s ear. This yields a +5 dB speech-to-noise ratio level.

Presentation Protocol The FLE should be conducted in the student’s typical hearing mode. If hearing aids or cochlear implants are usually worn at school, they should also be worn during the evaluation. When this evaluation is used as a validation tool to demonstrate improvement in listening ability with FM or other remote microphone hearing assistance technology, the examiner should repeat the far conditions to demonstrate the benefits of the technology. Eight phrase, sentence or word lists should be presented in the order indicated by the numbers on the scoring matrix. This order balances for difficulty across conditions so that the final task is the easiest of the far conditions. The examiner may choose to alter the order for other reasons however.

Scoring Scoring should be completed using the established procedures for the selected test material. Scoring may be made on total phrase/sentence correct or by number of words correct. In some situations it is useful to have another person (such as the classroom teacher) score the speech test materials. All scores should be reported in percent correct in the Scorebox on the Summary and Interpretation Form. Hearing assistance technology scores should be entered in the boxes labeled 9–12 for the far conditions repeated. A calculable PDF FLE form is available that populates the interpretation matrix from the Scorebox at http://www.ADEvantage.com.

Variations in Protocol This protocol is based on the listening situation of a typical classroom. For an individual student, it may be useful to modify this protocol to account for variations in the level and source of noise, classroom size, teacher’s voice, typical listening distances for the student, or other factors. In order to accommodate these variations, placement of the noise source, level of noise, distance from the student in the far condition, and order of presentation may be adjusted. Be sure to note these modifications on the test form.

Chapter 5

1. Auditory-Visual:

Close

Quiet

Interpretation Matrix

2. Auditory:

Close

Quiet

3. Auditory-Visual:

Close

Noise

4. Auditory:

Close

Noise

5. Auditory-Visual:

Far

Noise

6. Auditory:

Far

Noise

7. Auditory:

Far

Quiet

8. Auditory-Visual:

Far

Quiet

The Interpretation Matrix analyzes the effects of noise, distance, and visual input. It is completed by transferring the percentage correct scores from the Scorebox to the same numbered box in the interpretation matrix. Individual scores are summed and averaged to determine the overall effect of each condition. Although scores may be affected by different speakers, rate of speaking, attention of the listener, or status of amplification, comparisons are valid as long as these variables are kept constant throughout the evaluation.

When presenting the FLE via live voice, the examiner should present the speech materials at a normal speaking rate. Instruct the student to repeat the speech stimuli or point to the appropriate picture, as indicated by the material used. Repeat far conditions (9–12) to validate benefit of hearing assistance technology. Test administration takes approximately 30 minutes, including set up. For the auditory conditions it is recommended that the examiner use an acoustically transparent hoop over his/her face or instruct the student to look down during these conditions as placing a hand or paper in front of the talker’s mouth will change the acoustic characteristics of the speech sounds.

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When validating hearing assistance technology, the target for desired performance is the score from box 1 (for auditory visual) or box 2 (auditory only) of the Scorebox. In other words, the effects of noise and distance can be considered eliminated when the performance with the technology matches the individual’s best performance in quiet, or at least reduced, if the performance is improved. This information can be used as evidence to justify technology and other accommodations that may be beneficial for the student. The findings should be discussed with the student, his/her parents, and teachers to help them understand the student’s listening abilities and communication access options. A summary of the Interpretation Matrix and appropriate recommendations should be written on the scoring form.

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References

Johnson, Benson, & Seaton (1997). San Diego: Singular Publishing Group, Inc. Ross, M., Brackett, D. & Maxon, A. (1991). Communication Assessment. In Assessment and management of mainstreamed hearing-impaired children (113–127). Austin, Tx: Pro-Ed. Ying, E. (1990). Speech and Language Assessment: Communication Evaluation. In M. Ross (Ed.), Hearing-impaired children in the mainstream (45–60). Parkton, MD: York Press.

Chapter 5

Johnson, C.D. (2012). Common Children’s Phrases, Children’s Nonsense Phrases, In Educational Audiology Handbook (2nd Ed.) (150–153). Clifton Park, NY: Delmar Cengage Learning. Johnson, C.D. (2013). Functional Listening Evaluation. Available from http://www.ADEvantage.com Johnson, C.D. & VonAlmen, P. (1993). The Functional Listening Evaluation. In Educational audiology handbook, (336–339).

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Left Ear___% @ ___dBHL

Unaided h

h None h Hearing Aids h Cochlear Implant h Baha h Classroom Other__________

h Classroom h Other_________

2

close/quiet

4

3

close/noise

7

8

distant/quiet

6

5

distant/noise

5

6

7

8

3

4

1

quiet

noise

noiseaud/vis

noiseaud

quietaud-vis

quietaud

close

______% close

3

4

1

2

8

5

3

7

6

4

aud

______% ______% aud/vis aud

______% ______% aud/vis aud

distantquiet

distantnoise

closenoise

closequiet

2

Visual Input aud-vis 1

INTERPRETATION AND RECOMMENDATIONS

______% distant

______% distant

5

6

8

distant 7

Distance

With Hearing Assistance Technology: Average of above scores: ______% ______% ______% quiet noise close

Average of above scores: ______% ______% quiet noise

distantaud/vis

distantaud

closeaud/vis

closeaud

2

Noise

Age/DOB:

INTERPRETATION MATRIX

Examiner: __________________________________

Source: © C.D. Johnson, Updated 2013. Based on Functional Listening Evaluation by C.D. Johnson & P. V   on Almen, 1993. Available from www.ADEvantage.com, pdf fillable form from https://www.phonakpro.com/content/dam/phonakpro/gc_hq/en/resources/counseling_tools/documents/child_hearing_assessment_functional_listen ing_evaluation_fle_2017.pdf

auditory

auditoryvisual

1

distant -____dB

FUNCTIONAL LISTENING SCOREBOX

Modifications in protocol:

Approximate speech to noise levels: close +____dB

Noise level @ listener’s ear: ____dBA SPL

Speech level @ listener’s ear: ____dBA SPL ; @ 1 ft from examiner: ____dBA SPL

Noise Stimulus: h Multitalker

Distance (distant condition): ___ft

Assessment Material: ________________________________________________

Classroom Noise Level: Unoccupied ______dBA SPL; Occupied ______dBA SPL

Hearing Assistance Technology: h FM

Amplification:

FUNCTIONAL LISTENING EVALUATION CONDITIONS

Noise ___% @ ___dBHL @ ___S/N

Quiet ___% @ ___dBHL

Sound Field: Aided h

h 500, 1K, 2K

Word Recognition: Right Ear ___% @ ___dBHL

PTA used:

Left Ear ___dB h 1K, 2K, 4K

AUDIOMETRIC RESULTS

Date: _______________

Hearing Sensitivity: Pure Tone Ave: Right Ear ___dB

Name:

THE FUNCTIONAL LISTENING EVALUATION

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APPENDIX

5–I Classroom Participation Questionnaire-Revised Deaf/ Hard- of-Hearing Students

Student’s Name_____________________________________ Date Completed________________ School_____________________________________________ Grade _______________________ Teacher Administering Scale ___________________________ District_______________________ ELEMENTARY STUDENTS 3rd GRADE AND ABOVE complete this form for the regular education classroom. MIDDLE and HIGH SCHOOL STUDENTS complete this form for your Language Arts/English class. If you are not in the regular classroom for Language Arts/English, then complete the form for your Social Studies or Science class – whichever of these two classes has the most frequent discussions. Form completed for: ___ Language Arts/English ___Social Studies ___Science ___ Other (Please specify)

AT HOME 1. How often does your family use sign language?

Never

Sometimes

Often

All the time

2. a. Are there any other family members who have a hearing loss? No Yes b. IF YES, circle who: Father Mother Brother Sister Other_____________________

4. How do you like best for hearing students to communicate with you?

1

2

3

4

5

5. How do you like best to communicate with teachers?

1

2

3

4

5

6. How do you like best for teachers to communicate 1 with you?

2

3

4

5

7. How do you like best to communicate with other deaf/ hard-of-hearing students?

1

2

3

4

5

8. How do you like best for other deaf/ 1 hard-of-hearing students to communicate with you?

2

3

4

5

9. Do you typically use an interpreter in class? 10. How many other deaf/hard-of-hearing students are in your class(es)?

No 0

1-2

Chapter 5

IN SCHOOL- Please circle one answer for each question. If there are no other deaf/hard-of-hearing students in your class(es), ignore questions 7 and 8. Interpreter Sign Speech Speech Writing & Sign Notes 3. How do you like best to communicate with 1 2 3 4 5 hearing students?

Yes 3-4

5 or more

© Stinson, M., Long, G., Reed, S., Kreimeyer, K., Sabers, D. & Antia, S.D. (2006). Used with Permission.

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APPENDIX

5–J Auditory Problems Self-Checklist

Self-perceptions of listening problems are valuable to consider when identifying specific auditory problems experienced by students. This self-checklist should be used in combination with the Fisher’s Auditory Problems Checklist in order to compare specific self-perceptions of listening problems with observations obtained by a professional. The normative data on the Fisher’s Checklist was obtained by adult professionals and was not based on students’ own impressions. Scoring on Fisher’s Auditory Problems Checklist cannot reliably be applied to this protocol but is useful in comparing students’ own perceptions versus impressions of a professional. Student Name

Date Completed

School

Grade

The questions on this checklist will help your teachers understand your listening and comprehension skills. Please answer each question by CIRCLING “Yes” or “No.”

Chapter 5

YES YES YES YES YES YES YES

NO NO NO NO NO NO NO

YES YES YES YES

NO NO NO NO

YES YES YES YES YES YES YES YES YES

NO NO NO NO NO NO NO NO NO

YES NO YES NO YES NO YES NO YES NO

1. 2. 3. 4. 5. 6. 7.

Do you think you have a hearing problem? Do you have a history of hearing loss or ear infections? Do you have difficulty paying attention to your teacher? Do you often need directions repeated? Do you say “huh” or “what” five or more times per day? Do you have difficulty keeping your attention on what you are listening to? Do you have difficulty paying attention to your teacher? If yes, indicate about how long you can pay attention to your teacher? __0–2 min __2–5 min __5–15 min __15–20 min 8. Do you find yourself daydreaming in class? 9. Are you easily distracted by sounds or noises around you? 10. Do you have difficulty with phonics (sounding out words)? 11. Is it hard for you to hear differences between sounds in words (for example, mouth versus mouse, ran versus rain)? 12. Do you forget what is said a short time later? 13. Is it hard for you to remember simple routine things from day to day? 14. Do you have trouble remembering what you heard last week, last month, or last year? 15. Do you have trouble remembering a sequence of information that you have heard? 16. Do you experience difficulty following spoken directions? 17. Do you frequently misunderstand what is said? 18. Do you have difficulty understanding words or ideas that are told to you? 19. Is it hard for you to learn when the information is only spoken? 20. When you speak, do you have a hard time choosing the words you want to say or putting words together correctly? 21. Is your speech hard for others to understand? 22. Does what you see relate to what you hear? 23. Do you want to learn? 24. Do you need extra time to think about directions you are given? 25. Are you having difficulty in any of your classes? If so, which ones? _________________________ _________________________________________________________________________________ What are your best classes?___________________________________________________________

Note. Modified by Cheryl DeConde Johnson from Fisher’s Auditory Problems Checklist.

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APPENDIX

5–K

  

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  



    

      

                 

          

                     

                  

Chapter 5

               

  

  

                                             

Source: ©1991 Relationship of Degree of Long-term Hearing Loss to Psychosocial Impact and Educational Needs, Karen Anderson & Noel Matkin, revised 2007 thanks to input from the Educational Audiology Association. Reprinted with permission. https://successforkidswithhearingloss.com

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Chapter 5

   



















   

  

 



 



 

                                                                     



Chapter 5

   

  

           

  

  

                                             

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Assessment

 

 



















                                



  

       

     

                  

                      



Chapter 5

              

  

  

                                             

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Chapter 5

  



















  



                                                    

                               



Chapter 5

             





   

  

  

                                             

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  

 

 

                                            

                                        

                                                







Chapter 5



   

  

  

                                             

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Chapter 5

  

   



 

                     

                       

                           

Chapter 5

                   

  

  

                                             

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Assessment

  



















  

         

             

                

           



                             

Chapter 5

              

  

  

                                             

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Chapter 5

  



















 

  

 



  



 



     



                

     







 

          



  

 



    



  



 



 



   



    



Chapter 5

              

  

  

                                             

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Assessment

  





















 

  

    

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  

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 

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    





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   

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  

  

     

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  



  



   



    





   

  



   

   



 



      

Chapter 5

               

  

  

                                             

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Total

Date:

Grade:

9-20 minutes/week 21-37 minutes/week 35-50 minutes/week

9-16 17-24 25-32

0-14 minutes/week

(in minutes/week)

Ratings

0-8

Guideline for Considering Range of Service

Impact Score

Eligibility:

Hearing Age:

This is NOT to suggest that all students must be seen weekly. This is only a guideline for the individualized education program (IEP) team to consider.

Total

Notes:

Teacher Consultant/Itinerant Teacher:

District:

School:

Age:

Birth Date:

Student Name:

Note. Used with permission. Complete Matrix with instructions for use is available at https://mdelio.org/sites/default/files/documents/DHH/ServiceDeliveryTools /ImpactMatrix/Impact_Matrix_For_Students_who_are_Deaf_or_Hard_of_hearing_V2.7.2.pdf

When calculating the total Educational Impact Score, round up to the next integer.

Total A +/- Total B (Optional) =

Educational Impact Score

Total Points B

Others

Attendance/Challenging Condition

Change in Program

Additional Supports

Student Cooperation

+/- .5 Points

(Optional)

Points

B. Contributing Factors

Total Points A

VI. Personal Adjustment and Transition

V. Academic/Vocational Performance

IV. Use of Amplification Devices

III. Functional Listening Skills

II. Language/Vocabulary

I. Audiological Factors

(Matrix)

A. Factors for Consideration

Student Profile

Chapter 5

03

APPENDIX

5–L

Michigan Department of Education—Low Incidence Outreach Educational Impact Matrix for Students Who Are Deaf or Hard of Hearing (DHH)

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04

(0-4)

Points

One year/grade level below on standardized assessments English Language Arts (ELA) core standards for Reading, Writing, Listening, Speaking, and Language scores 70-79% on age/grade level through 5th grade conventions Intermittently participates in classroom and social interactions without prompts

At or above age/grade level on standardized assessment

English Language Arts (ELA) core standards for Reading, Writing, Listening, Speaking, and Language scores more than or equal to 80% on age/grade level through 5th grade conventions

Participates, initiates, and sustains classroom and social interactions

Chapter 5

4 Points

0 Points

Participates in classroom and/or social interactions with prompts

English Language Arts (ELA) core standards for Reading, Writing, Listening, Speaking, and Language scores 60-69% on age/grade level through 5th grade conventions

Two years/grade levels below on standardized assessments

6 Points

Rarely participates in classroom and/or social interactions, with or without prompts

English Language Arts (ELA) core standards for Reading, Writing, Listening, Speaking, and Language scores less than or equal to 59% on age/grade level through 5th grade conventions.

Three years/grade levels below on standardized assessments

8 Points

(0-8)

Points

Language/vocabulary includes the level of language and vocabulary skills acquired as measured by standardized assessments and/or English Language Arts Core Standards. It also includes student’s use of language for interaction with teachers and peers.

II. Language/Vocabulary

Auditory neuropathy

Chronic middle ear problems; difficult to manage

Frequent, manageable middle ear problems

Aided speech discrimination 85% or above

Speech discrimination of 85% or above without amplification

History of progressive hearing loss Aided speech discrimination less than 70%

Fluctuating hearing loss

Occasional middle ear problems

Unilateral hearing loss

Bilateral severe to profound hearing loss: above 70 dB PTA

4 Points

Aided speech discrimination 7084%

Bilateral moderately severe hearing loss: 56-70 dB PTA

Bilateral moderate hearing loss: 41-55 dB PTA

Bilateral slight to mild hearing loss: 16-40 dB PTA

3 Points

2 Points

0 Points

Audiological factors (medical) include the student’s type and level of hearing as well as listening discrimination scores, as reported by an audiologist and/or an otolaryngologist/otologist.

I. Audiological Factors

Educational Impact Matrix for Students who are Deaf or Hard of Hearing (DHH)

05

Plural_Johnson_Ch05.indd 172

Understands classroom vocabulary with support Understands class content in small groups with minimal background noise

Understands concepts and vocabulary

Gains information

Recognizes environmental sounds

Understands single words and short familiar phrases supported with speech reading

Responds appropriately to familiar routines Understands part of class content in small groups and a quiet setting

Develops auditory skills within closed sets

8 Points

Responds appropriately to familiar words and phrases

6 Points

Limited knowledge of amplification devices Identified and amplified in last 6-12 months Needs occasional assistance with use and care Reports functioning status of personal amplification devices and/or HAT with at least 75% accuracy Uses amplification at school but not at home

Identified/amplified more than one year ago

Independent use and care

Reports functioning status of personal amplification devices and/or hearing assistive technology (HAT) with 90% accuracy

Uses amplification at home and school

2 Points

Amplification devices not prescribed

0 Points

Uses amplification inconsistently at home and/or school

Reports functioning status of personal amplification devices and/or HAT with at least 50% accuracy

Needs regular assistance with use and care

Identified and amplified within last 6 months

Declines use of amplification devices

3 Points

Uses amplification at school less than 50% of day

Reports functioning status of personal amplification devices and/or HAT with at least 20% accuracy

Needs daily assistance with amplification

Identified and amplified within last 3 months

Does not benefit from amplification devices

4 Points

Amplification devices may include hearing aids, cochlear implants, personal FM, classroom system, or other hearing assistive technology (HAT).

IV. Use of Amplification Devices

Follows conversational topics easily

Obtains class content given cues about topic

4 Points

Understands connected speech

0 Points

Functional listening skills includes the student’s ability to use listening skills in a variety of settings.

III. Functional Listening Skills

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(0-4)

Points

(0-8)

Points

173

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06

Has significant content modifications and numerous accommodations

Advocates for technology and accommodations with minimal support Knows and uses resources for access in familiar settings

Advocates for technology and accommodations independently

Knows and uses resources for access in familiar and novel settings

Chapter 5

2 Points

0 Points

Uses few resources for access in current setting and needs support to adjust to new setting

Advocates for technology or accommodations 1-2 times per week with prompts

3 Points

Needs information and training for access in new setting

Does not advocate for self with or without prompts

4 Points

Personal adjustment and transition includes the level of self advocacy for technology and/or accommodations as well as skills necessary for transitions including graduation and/or change of levels.

VI. Personal Adjustment and Transition

Has content modifications and accommodations

Has IEP or 504 accommodations supporting listening, hearing, and access to instruction

Has no IEP or 504 accommodations

General education teacher reports development of skills necessary to meet 50% of core standards

General education teacher reports development of skills necessary to meet 60% of core standards

General education teacher reports development of skills necessary to meet 70% of core standards

General education teacher reports development of skills necessary to meet 80% of core standards.

State or district testing indicates no interference with educational and/or vocational performance

State or district testing indicates significant impact on educational and/or vocational performance

Partially Proficient on state assessment for ELA/writing

Advanced/Proficient on state assessment for ELA/writing State or district testing indicates moderate impact on educational and/or vocational performance

4 Points

State or district testing indicates minimal impact on educational and or vocational performance

3 Points

Not Proficient on state assessment for ELA/writing or on Alternate State Assessment

2 Points

Partially Proficient/Not Proficient on state assessment for ELA/ writing

0 Points

Academic/vocational performance includes the level of academic progress and/or career-related learning as well as the student’s need for accommodations or modifications.

V. Academic/Vocational Performance

(0-4)

Points

(0-4)

Points

APPENDIX

5–M General Teacher Letter

[NAME OF PROGRAM] Dear (Insert teacher’s name), A student in your classroom, help your student by: ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

, has a hearing loss. You can

Facilitating acceptance of the student. Being sure hearing aids and/or other hearing technologies are used as recommended. Providing preferential or flexible seating. Increasing use of visual information. Minimizing classroom noise. Using clear speech and encouraging others to do so. Modifying teaching techniques. Having realistic expectations. Asking ______________ for input on his/her needs in your classroom.

Chapter 5

Specific suggestions to help you accomplish these things are listed in the following material. These guidelines are general and should be adapted as necessary. The items marked with an asterisk (*) are especially important for your student. If you have any questions, please contact me for assistance.

Sincerely,

Educational Audiologist (insert name and contact information)

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Assessment

175

FACILITATE ACCEPTANCE OF YOUR STUDENT: Your student will benefit from a classroom where he/she feels accepted and where modifications are made without undue attention. ■■ ■■ ■■ ■■ ■■ ■■

Welcome the student to your class. Your positive attitude will help other students accept him/her. Discuss your student’s hearing loss with him/her; let him/her know you are willing to help. As appropriate, have your student, the audiologist, or another person explain the student’s hearing loss to your entire class. Make modifications seem as natural as possible so the student is not singled out. Accept your student as an individual; be aware of his/her assets as well as his/her limitations. Encourage your student’s special abilities or interests.

BE SURE HEARING AIDS AND OTHER HEARING TECHNOLOGIES ARE USED AS RECOMMENDED: This will enable your student to access sound and speech in the classroom. ■■ ■■ ■■ ■■ ■■

Realize that hearing aids make sounds louder, but not necessarily clearer. Hearing aids don’t make hearing normal. Be sure your student’s hearing aids or other devices are checked daily to see that they are working properly. Encourage the student to care for his/her hearing aid(s) by putting it on, telling you when it is not functioning properly, etc. Be sure your student always has a spare battery at school. Know who to contact if your student’s device is not working properly.

PROVIDE PREFERENTIAL SEATING: Appropriate seating will enhance your student’s ability to hear and understand what is said in the classroom. ■■

■■

■■ ■■ ■■ ■■

Seat near where you typically teach. It will be helpful if your student is at one side of the classroom so that he/she can easily turn and follow classroom dialogue. Seat where your student can easily watch your face without straining to look straight up. Typically the second or third row is best. Seat away from noise sources, including hallways, HVAC systems, pencil sharpeners, etc. Seat where light is on your face and not in your student’s eyes. If there is a better ear, place it toward the classroom. Allow your student to move to other seats when necessary for demonstrations, classroom discussions, or other activities.

■■

■■ ■■

■■

Remember your student needs to see your face in order to lipread! …… Try to stay in one place while talking to the class so your student does not have to lipread a “moving target.” …… Avoid talking while writing on the chalkboard. …… Avoid putting your hands, papers, or books in front of your face when talking. …… Avoid talking with your face turned downward while reading. …… Keep the light on your face, not at your back. Avoid standing in front of windows where the glare will make it difficult for your student to see your face. Use visual aids, such as pictures and diagrams, when possible. Demonstrate what you want the student to understand when possible. Use natural gestures, such as pointing to objects being discussed, to help clarify what you say. Use the chalkboard--write assignments, new vocabulary words, key words, etc. on it.

Chapter 5

INCREASE VISUAL INFORMATION: Your student will use lipreading and other visual information to supplement what he/she hears.

MINIMIZE CLASSROOM NOISE: Even a small amount of noise will make it very difficult for your student to hear and understand what is said. ■■ ■■

Seat your student away from noisy parts of your classroom. Wait until your class is quiet before talking to them.

USE CLEAR SPEECH AND ENCOURAGE OTHERS TO DO SO ALSO: Clear speech will help your student understand you and others better. ■■ ■■ ■■

Speak naturally in a good, clear voice. It is not necessary to shout or exaggerate lip movement. Use a moderate rate of speech. Pause briefly between phrases to allow time for auditory processing.

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176

Chapter 5

MODIFY TEACHING PROCEDURES: Modifications will allow your student to benefit from your instruction and will decrease the need for repetition. ■■ ■■ ■■ ■■ ■■ ■■

■■

Be sure your student is watching and listening when you are talking to him/her. Be sure your student understands what is said by having him/her repeat information or answer questions. Rephrase, rather than repeat, questions and instructions if your student has not understood them. Write key words, new words, new topics, etc. on the whiteboard. Repeat or rephrase things said by other students during classroom discussions. Introduce new vocabulary to the student in advance. The speech-language pathologist or parents may be able to help with this. Use a “buddy” to alert your student to listen and to be sure your student has understood all information correctly.

HAVE REALISTIC EXPECTATIONS: This will help your student succeed in your classroom. ■■

■■ ■■

■■ ■■

■■

■■ ■■

Remember that your student cannot understand everything all of the time, no matter how hard he/she tries. Encourage him/her to ask for repetition. Be patient when student asks for repetition. Give breaks from listening when necessary. Your student may fatigue easily because he/she is straining to listen and understand. Expect student to follow classroom routine. Do not spoil or pamper your student. Expected your student to accept the same responsibilities for considerate behavior, homework, and dependability as you require of other students in your classroom. Ask the student to repeat if you can’t understand him/her. Your student’s speech may be distorted because he/she does not hear sounds clearly. Work with the speech-language pathologist to help your student improve his/her speech as much as possible. Be alert for fluctuations of hearing due to middle ear problems. Request support from the audiologist, the speech-language pathologist, or others when you feel uncertain about your student and what is best for him/her.

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APPENDIX

5–N Ordering Information for Selected Assessment Products

Auditory Perception Test for the Hearing Impaired (APT) Plural Publishing, Inc. 5521 Ruffin Road San Diego CA 92123 (866) 758-7251 FAX: (888) 758-7255 https://www.pluralpublishing.com Bamford-Kowal-Bench Speech-In-Noise Test (BKB-SIN) Etymotic Research https://www.etymotic.com Children’s Auditory Performance Scale (CHAPS) Educational Audiology Association 3030 W. 81st Street Westminster CO 80031-4111 (800) 460-7322 http://edaud.org Children’s Home Inventory for Listening Karen Anderson Audiology Consulting Difficulties (CHILD) https://successforkidswithhearingloss.com Children’s Outcome Worksheets (COW) Oticon Corporation  http://www.oticonus.com/ProfessionalSection /EducationalForms Chapter 5

Classroom Participation Questionnaire (CPQ) ADVantage Consulting https://www.advantage.com Cottage Acquisition Scales for Listening, Sunshine Cottage School for Deaf Children Language and Speech (CASLLS) 103 Tuleta Dr. San Antonio, TX 78212 (210) 824-0579 https://www.sunshinecottage.org Developmental Index of Audition and Listening (DIAL)

Educational Audiology Assoc. (see above)

Early Speech Perception Test (ESP) Central Institute for the Deaf 825 South Taylor Avenue St. Louis, MO 63110 (877) 444-4574; (314) 977-0132 FAX: 314-977-0023; TTY: 314-977-0037 https://cid.edu Early Listening Function (ELF)

Educational Audiology Assoc. (see above)

Fisher’s Auditory Problems Checklist

Educational Audiology Assoc. (see above)

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Functional Auditory Performance Indicators (FAPI) https://www.arlenestredlerbrown.com Karen Anderson Audiology Consulting (see above) Functional Listening Evaluation (FLE) ADVantage Consulting (see above) Lexical Neighborhood Test (LNT) and Multi-syllabic Neighborhood Test (MLNT)

Auditec of St. Louis https://auditec.com

Listening Inventory for Education (LIFE) Karen Anderson Audiology Consulting (see above) LittlEARS Auditory Questionnaire MedELCorporation https://www.medel.com Meaningful Auditory Integration Scale (MAIS) Advanced Bionics Corporation Mann Biomedical Park 25129 Rye Canyon Loop Valencia, CA 91355 (800) 678-2575 https://www.bionicear.com

Chapter 5

Minimal Auditory Capabilities Battery (MAC Battery)

Auditec of St. Louis (see above)

Northwestern University Children’s Perception of Speech (NU-CHIPS)

Auditec of St. Louis (see above)

Pediatric Speech Intelligibility (PSI)

Auditec of St. Louis (see above)

Screening Instrument for Targeting Educational Risk (SIFTER) (Original, Preschool, Secondary) Sound Effects Recognition Task (SERT)

Karen Anderson Audiology Consulting (see above)

Word Intelligibility by Picture Identification (WIPI), 2nd edition

Auditec of St. Louis (see above)

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Auditec of St. Louis (see above)

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CHAPTER

6

Auditory Processing Deficits With Lisa R. Cannon

CONTENTS

Chapter 6

Auditory Processing Deficit Basics Terminology and Definitions of Auditory Processing and Auditory Processing Deficits and Disorders ■ Criteria for Determination of an Auditory Processing Disorder ■ Practice Guidelines: The Role of the Audiologist and Other Professionals ■ APD and Other Disorders An Educational Model of Auditory Processing APD and Multitiered Systems of Support Implementing a School-Based APD Program Step 1. Developing the APD Team and Philosophy ■ Step 2. Referral and Screening ■ Step 3. Assessment for APD ■ Step 4. Eligibility for Services ■ Step 5. Intervention

“It’s so much harder for me to understand in my noisy classroom and the lunchroom than listening in my quiet home.”

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CONTENTS 

(Continued )

Summary Suggested Readings and Resources Appendices 6–A Auditory Processing Deficit Screening Questionnaires (Text/Online) 6–B Referral for Auditory Processing Assessment (Text/Online) 6–C Auditory Processing Case History (Text/Online) 6–D Auditory Processing Assessment Resources (Text) 6–E Supplemental and Multidisciplinary Tests of Auditory Processing (Text) 6–F Auditory Processing Assessment Profile (Text/Online) 6–G Accommodations and Modifications Checklist for Auditory Processing Deficits (Text/Online) 6–H Computer-Based Auditory Training Programs (Text) 6–I Instructional Interventions for Students With Auditory Processing Deficits (Text/Online) 6–J A Multitiered Model of Auditory Processing Deficit Interventions (Text)

KEY TERMS APD, CAPD, RtI, MTSS, remote microphone hearing assistance technology (RM HAT), processing, CANS, ADHD, SLI, SLD, comorbidity, executive functioning, multidisciplinary, dichotic listening, temporal processing, neuromaturation, neuroplasticity, top-down, bottom-up, computerbased auditory training, deficit-specific intervention, compensatory strategies, metacognitive

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School professionals, including educational audiologists, are tasked with identification of educational dis-

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abilities rather than specific disorders, such as auditory processing “disorder.” A meaningful audiological auditory processing deficit (APD) assessment should minimize the confounding factors of other disorders and be inclusive of additional assessments that examine the entire continuum of listening including linguistic and cognitive components. Despite the controversies that exist in the field, one point of agreement in all APD guidance documents and literature is the importance of a team approach to APD. By considering the individual listener, the message, and the environment, an intervention plan can offer a holistic approach to managing APD in the school setting. The growing availability of laptops and tablets in the classroom as well as the use of skill-building computer programs in general should increase the likelihood that

The Challenge Is Real An informal 2018 survey of 38 educational audiologists practicing in different school systems in Colorado provides valuable insight into the controversies and challenges surrounding assessment and management of APDs in the school setting. Twenty percent of the respondents reported they do not offer APD testing at all. Of those, about a half cite time constraints, and a quarter report that they do not feel like there are adequate guidelines for testing, including a lack of sensitive screening tools, efficient test battery, and proven interventions.  Add that to the fact that of those who do provide APD assessments,

most (75%) estimate only 1 to 20 referrals per school year, which makes it difficult to stay current with the research and adds challenges to feeling comfortable in assessment and interpretation practices. Referrals are not going away, however, as 61% of respondents indicated that they think referrals are on the rise. About half of referrals reportedly come from a speech-language pathologist (SLP), but about 20% are initiated by parents. APD assessment is a continuing demand, and educational audiologists in particular find themselves with plenty of questions and remain in need of ongoing guidance.

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One of the most challenging areas for educational audiologists is the identification and intervention of auditory processing deficits (APDs). Those who have worked with students are well aware of auditory processing problems and their educational impact. As a result of ongoing research and the growing body of knowledge about APDs, identification and intervention are acquiring a more scientific basis. Growing public awareness and interest in APDs by both parents and educators has resulted in steady referrals to educational audiologists, who must be vital members of the educational team to help determine whether an APD is causing or contributing to learning difficulties.

AUDITORY PROCESSING DEFICIT BASICS An initial step in addressing APDs is understanding what it is. Common questions related to understanding APD include the following: ■■ ■■

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What is an auditory processing deficit or disorder? What behavioral characteristics do children with APD have? How are they differentiated from learning disabilities, language disorders, and attention deficits? Are all auditory processing disorders the same, or are there different types of disorders? What are the educational implications of APD? How are APD services determined? How is APD treated?

Terminology and Definitions of Auditory Processing and Auditory Processing Deficits and Disorders Several agreed upon definitions of APD exist in the audiology literature. The American Speech-Language-Hearing Association (1996, 2005a) and the American Academy of Audiology (2010) convened task forces of APD experts to develop consensus on the topic and guidance for the profession. The definitions in these documents provide a foundation on which to build; however, they are complex and not easily understood by some professionals, much less teachers and parents. In general, defining APD involves defining both the processes it refers to, as well as the disorder or deficit that results when these processes are deficient. Our knowledge of the function of the central auditory nervous system (CANS) serves as the basis for what audiologists call “auditory processing” or “central auditory pro-

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cessing.” These processes or mechanisms, which occur in the CANS, underlie the following skills: ■■

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binaural processing (spatial processing, localization, lateralization, dichotic listening, binaural interaction); temporal processing (pattern recognition, ordering, reso­ lution); and speech processing (identification of and discrimination of degraded speech or speech-in-noise).

An APD refers to difficulty in one or more of these skills, originating in the CANS, which is not a result of higher-order linguistic or cognitive factors and is specific to the auditory modality. APD, especially in children, can lead to difficulties with listening and learning; therefore, it is often complicated to differentiate APD from other childhood disorders. Differentiating a central auditory processing deficit from issues of language, communication, learning, executive functioning, and other processing problems is undoubtedly the most challenging aspect of APD assessment. Research has shown that a majority of children identified with learning and language disorders will also perform poorly on audiological tests of auditory processing (Sharma, Purdy, & Kelly, 2009). In fact, the biggest controversy in the field of childhood APD is whether a diagnosis of APD can be valid or considered a unique disorder given the fact that it is nearly impossible to separate the sensory and cognitive components of listening (Moore, 2018). Educational audiologists find themselves in somewhat controversial territory while also managing the demand for providing APD assessments. A meaningful audiological APD assessment should minimize the confounding factors of other disorders and be inclusive of additional assessments that examine the entire continuum of listening including linguistic and cognitive components.

Terminology A clarification of terminology is necessary to communicate effectively about auditory processing and auditory processing deficits.

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schools can offer some of these specific listening programs for students identified with APDs. A common problem encountered by children with APD is difficulty understanding in noisy environments; therefore, technology that improves the signal-to-noise ratio has the possibility of benefiting the student.

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Nuggets from the Field The term “auditory processing” is used by speechlanguage pathologists (SLPs), psychologists, and audiologists. To a speech pathologist, the term is associated with linguistic processing. T   o a psychologist, it refers to the auditory form of cognitive processing. To an audiologist, it is a deficit in the processing of auditory input, specific to the auditory modality that occurs in the auditory system prior to cognitive and linguistic operations.

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Deficit Versus Disorder  Disorder is a specific term used in the medical community and is relevant for diagnosis, coding, and billing. Auditory processing disorder is often diagnosed in the clinical or medical setting in addition to the school set­ ting. The fact that a child may be diagnosed with an AP disor­ der does not necessarily mean he or she will also be consid­ ered a “child with a disability” at school under the federal and state regulations pertaining to students with disabilities. School professionals, including educational audiologists, are tasked with identification of educational disabilities rather than disorders. Educational disabilities occur along a continuum of severity, and some require minimal accommodations while others require special education supports and services. In the educational setting, use of the term “deficit” rather than “disorder” allows for flexibility in addressing students with a range of issues. Auditory Processing Disorder Versus Central Auditory Processing Disorder  Lack of consensus remains about the interchangeable use of APD, CAPD, or (C)APD. Most agree that the inherent difficulty in isolating “central” from other higher-order processing skills during behavioral eval­uation dictates that we should use the broader term of APD. Every­ day processing of speech and functional listening involve much more than just the auditory modality. However, recent recommendations from the American Speech-LanguageHearing Association (ASHA) practice portal (2018, www .asha.org/Practice-Portal/Clinical-Topics/Central-Auditory -Processing-Disorder/) have reintroduced the use of CAPD to attempt to differentiate problems arising with the acoustic signal from the more general auditory perceptual, language, and cognitive processing difficulties. Using the term “cen­ tral” may help to define the relevant assessment, clarify the multidisciplinary roles, and/or lead to more deficit-specific interventions.

Chapter 6

Criteria for Determination of an Auditory Processing Disorder The diagnosis of an AP disorder may be made only after appropriate peripheral and central assessments have been completed (see assessment for APD for this discussion). While many factors contribute to the presence of APDs, when test performance can be associated with significant learning problems and when test interpretation supports a diagnosis that can be differentiated from related deficits that have overlapping attributes such as ADHD, language deficits, cognitive deficits, or learning disabilities, a diagnosis of AP disorder may be made (American Speech-LanguageHearing Association, 2005). Currently, the ASHA practice portal includes the following criteria for diagnosis of an auditory processing disorder: ■■

Performance deficits are noted in one or both ears of at least two standard deviations below the mean on two or more testes in the battery (Musiek & Chermak, 1997).

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If poor performance is observed on only one test: …… Diagnosis may be withheld unless performance falls at least three standard deviations below the mean or the finding is accompanied by significant functional difficulty in auditory behaviors that rely on the process being assessed. …… The failed test—and other tests that assess the same process—should be readministered to confirm initial findings. Administering and comparing results for several tests that measure the same auditory process can be used to look for patterns in auditory processing abilities and to support the findings of the evaluation. Inconsistencies across tests might signal the presence of a nonauditory confound, even when CAPD criterion is met. Likewise, pervasive deficits on all tests may signal a cognitive deficit or other nonauditory confound.

These issues are discussed further under the assessment section of this chapter.

Practice Guidelines:  The Role of the Audiologist and Other Professionals The use of professional practice guidelines is particularly important in situations such as APD, where practices lack consensus or are not well defined. The ASHA Central Auditory Processing Disorder practice portal (2018), and the AAA Clinical Practice Guidelines: Diagnosis, Treatment and Management of Children and Adults with Central Auditory Processing Disorder (2010) provide a framework and guidance for developing and managing APD assessment and intervention services. Several international guidance documents, notably from Britain (2018) and Canada (2012), offer perspectives on the need to approach APD holistically, emphasizing the importance of relating testing to everyday hearing and listening functions. In addition, white papers and conferences on APD give audiologists the opportunity to remain up to date with current and changing research and practices. Despite the controversies that exist in the field, one point of agreement in all APD guidance documents and literature is the importance of a team approach to APD. Schools have an advantage because multidisciplinary assessment and management of students are typically the norm. The learning disabilities or special education teacher along with the related services professional team, which includes the audiologist, SLP, school psychologist, social worker, school nurse, and occupational and physical therapists, each provide a unique contribution when evaluating the many facets that impact the functioning of the neurological system as it relates to auditory processing. These contributions are present from the pre-referral process through intervention planning and benefit the student through a strengthened assessment process. However, when the decision regarding the identification of an auditory processing disorder is to

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Remaining informed of research in the area of CAPD as related to the audiologist’s contribution to patient management. Educating other professionals about the needs of individuals with CAPD and the role of audiologists in CAPD management. Participating in interdisciplinary team consultation for the assessment and management of CAPD. Conducting comprehensive audiologic evaluations. Obtaining a CAPD-specific case history. Selecting an appropriate and individualized CAPD test battery. Administering CAPD-specific assessments and interpreting the results. Diagnosing CAPD. Communicating results and recommendations to the patient/family and other appropriate parties. Developing and implementing culturally and linguistically appropriate assessment and intervention plans as part of an interdisciplinary team. Proceeding with assessment and fitting for hearing assistive technology systems (HATS), as appropriate. Providing education and counsel to the patient and family. Referring the patient to other professionals, as needed, to facilitate access to comprehensive services (e.g., speech-language pathology, psychology, neuro-otology, and neuropsychology).

The ASHA practice portal also lists roles and responsibilities specific to SLPs involved in the assessment and management of CAPD and language processing disorders. These are as follows: ■■

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Remaining informed of research in the area of CAPD as related to the SLP’s contribution to patient management. Educating other professionals about the needs of individuals with CAPD and the role of SLPs in CAPD management. Participating in interdisciplinary team consultation for the assessment and management of CAPD. Collecting information about skills related to auditory processing (e.g., auditory working memory, auditory comprehension) using a variety of screening and assess­ ment instruments. Conducting comprehensive cognitive-communication and speech and language assessments. Obtaining a CAPD-specific case history. Identifying the cognitive-communicative and/or speech and language factors that may be associated with CAPD. Providing a clinical description of the patient’s speech perception. Helping to identify or differentiate disorders in phonology or language processing that may be comorbid to CAPD.

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Helping to determine the precise nature of the diagnosed disorder(s) and the functional implications associated with the disorder(s). Communicating results and recommendations to the patient/family and other appropriate parties. Developing and implementing culturally and linguistically appropriate assessment and intervention plans as part of an interdisciplinary team. Providing education and counsel to the patient and family. Referring the patient to other professionals, as needed, to facilitate access to comprehensive services (e.g., audiology, psychology, and neuropsychology).

As indicated in the Code of Ethics (ASHA, 2016a), audiologists and SLPs who work in this capacity should be specifically educated and appropriately trained to do so.

APD and Other Disorders The incidence and prevalence of childhood developmental, language, learning and behavior disorders complicates the identification of APD because it necessitates a multidisciplinary assessment. A full discussion of the comorbidity or coexistence between APD and other disorders is covered in detail in multiple chapters of Musiek and Chermak’s Hand­ book of (central) auditory processing disorders (2014) as well as in Geffner and Ross-Swain’s Auditory processing disorders: Assessment, management, and treatment (2019). Consider the following U.S. estimates: ■■

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By age 3 years, 30% of children experience three or more episodes of otitis media (OM) (NIDCD); early OM has lasting impact on the development of auditory processing abilities (Downs, 2004). One in five children in the United States have learning and attention issues (NCLD, 2017). Approximately 5% to 6% of public school students have Individualized Education Programs (IEPs) for specific learning disabilities (SLDs) (NCLD, 2017). One-third of those identified with SLD also have attention deficit hyperactivity disorder (ADHD) (NCLD, 2017). About 9.4% of children 2 to 17 years of age had ever been diagnosed with ADHD (CDC, 2018). Nearly two of three children with current ADHD had at least one other mental, emotional, or behavioral disorder (CDC, 2018). Approximately 2% to 7% of school-age children are estimated to have APDs with a 2:1 ratio of boys to girls (Musiek & Chermak, Handbook of (Central) Auditory Processing Disorder, Volume I, 2007).

Chapter 6

be made, it is the audiologist’s responsibility, based on our scope of practice, to do so. The specific roles of the audiolo­ gist are defined by the ASHA practice portal as follows:

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The comorbidity issues become readily apparent as one considers the neurologic continuum of auditory processing described by Richard (2019) that is required. This continuum begins as an acoustic signal is received in the peripheral auditory system (external, middle, and inner ear),

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then transferred and processed auditorily for discrimination of the acoustic characteristics of the sound (central auditory nervous system and the auditory nerve and brainstem), then transferred for phonemic processing (Heschl’s gyrustemporal lobe), then to language processing for discrimination of linguistic characteristics of the sound, attaching meaning, and integrating the various components of the signal (Wernicke’s area-temporal lobe and angular gyrus), and finally executive function resulting in planning and execution of a response (prefrontal/frontal lobe and motor strip). Assessment needs to consider how all components on this continuum, as well as other contributing factors including attention, motivation, language competence and experience, and cognitive ability, contribute to performance.

AN EDUCATIONAL MODEL OF AUDITORY PROCESSING There are a variety of theoretical frameworks from which to view auditory processing. Early researchers developed many of the tests still used today to identify specific sites of lesions in the CANS to explain auditory deficits. Today, practicing audiologists want to understand more about the function of the auditory system, especially in children, where there is rarely an etiology available to describe the difficulties. Kraus and Smith (2019) proposed an auditory-cognitive neuroscience framework in which the CANS does not act alone in processing auditory information and that auditory learning is shaped by cognitive and environmental influ-

Being able to provide deficit-specific, targeted, and effective interventions depends on being able to differentiate problems in the auditory modality from other areas, and this is the primary purpose of APD assessment in school-age children. A multidisciplinary team approach is imperative in order to accomplish this task.

ences over a lifetime. Interactions within and among different brain systems shape the efficiency and effectiveness of listening skills. In their model, assessment and remediation should include a holistic approach. Educational audiologists are tasked with helping school teams determine whether an auditory-based deficit is impacting a student’s learning. In order to do this, it is helpful to consider an audiological assessment of APD as only one aspect of examining auditory processing abilities. A proposed educational model of APD (as shown in Figure 6–1) is inclusive of the multimodal factors, skills, and professionals involved in understanding and assessing listening abilities (Colorado Department of Education, 2019). Top-down, cognitive processes including attention, memory, and nonverbal problem-solving interact with linguistic abilities that interact with bottom-up auditory and other sensory processes in a dynamic circle that complicates our ability to determine the “root cause” of a student’s struggles.

APD and Multitiered Systems of Support

Chapter 6 FIGURE 6–1  Educational model of APD. (From Colorado Department of Education, Exceptional Student Leadership Unit, Guidelines for educational evaluation and intervention of auditory processing deficits [2019 revision in process]. Used with permission.)

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Trends in both general and special education have shifted to include practices that support students with various levels of interventions. The Individuals with Disabilities Education Act (IDEA) 2004 introduced Response to Intervention (RtI), which was intended to ensure that children with learning and behavior problems were not referred to special education because of lack of adequate instruction or support within the general education classroom. RtI evolved into a more holistic, problem-solving approach know as Multi-Tiered System of Supports (MTSSs). While each state or education system may approach RtI/MTSS differently, the general purpose is the same: to provide a prevention-oriented, systematic process of delivering interventions based on demonstrated levels of need. This multitiered approach continues to evolve within current general education and special education policy including the Every Student Succeeds Act (ESSA, 2015) and the developing reauthorization of IDEA. The hallmark of MTSS is its focus on evidence-based practices that are monitored for effectiveness and result in high-quality, individualized instruction at three different levels. A detailed description of the RtI/MTSS model can be found at the RtI Action Network website (http://www.rtinetwork.org).

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What kind of information is needed to clarify the student’s problem? Who should be involved in determining the interventions at the various levels? How many interventions need to be applied before a student moves to the next level of interventions and ultimately a referral for special education? How long should each intervention be applied? How should student progress be monitored?

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Further, sufficient support must be available to the general education teacher who is responsible for implementing the strategies to assure that the fidelity (e.g., quality, of implementation) is sufficient to conclude that the intervention failed rather than how it was implemented.

IMPLEMENTING A SCHOOL-BASED APD PROGRAM Designing and implementing a process for APD assessment and intervention requires good planning. A useful strategy is to design the plan, conduct trial implementation, and then review the process and make revisions. The following steps will help to guide you through this process.

Step 1. Developing the APD Team and Philosophy This is the time to gather your colleagues in speech-language pathology, school psychology, and learning disabilities. You might start by discussing professional perspectives to begin to develop a philosophy that will guide your planning. For example, examine professional practices within audiology, speech-language pathology, and school psychology. Consider your occupational therapist to understand the connections with sensory processing disorders and your school nurse for medical and developmental areas. Gain consensus on an educational model of APD that the entire team can get behind. Developing an FAQ (Frequently Asked Questions) about APD serves to document the shared understanding of the team on a variety of issues including what APD is, how it is assessed, how students are eligible for special education with APD, and what interventions are available to address APD. Once everyone is comfortable with the topic and agrees on the need for an APD assessment process, proceed by identifying your purpose and developing a plan complete with activities and timelines. The plan should include activities to build awareness of APD, identification indicators, screening and assessment procedures, and management considerations. These activities should minimally encompass audiology, speech-language pathology, and cognitive domains. Be sure to identify resources, specifically tests and other materials, that are necessary to implement your plan. The steps described in the following sections will primarily pertain to the audiologist’s role in this process.

Chapter 6

Students with APD are generally referred for concerns involving learning, behavior, or speech and language, which are interfering with academic progress. These students would likely proceed through the RtI/MTSS process in their school before being referred to special education and, hence, the APD evaluation. Considerations include data that are already collected through the RtI/MTSS process and whether the parent has requested an evaluation. If a parent requests an evaluation, the school needs to either proceed with the evaluation or decline the request by issuing a prior written notice that provides the parents with a response and a reasonable period of time to address their concern. Generally, APD assessment would occur as part of the special education referral process rather than the RtI/MTSS process. Because audiologists are not usually routine members of the building team, it is helpful for them to provide the team information about common symptoms of APD, possible management strategies that could be implemented under RtI/MTSS, as well as referral criteria. These areas will be discussed again under designing APD programs. Appendix 6–J contains an MTSS model as it might be adapted for students with APD (Colorado Department of Education, 2008). Each tier provides successively more intense interventions. The universal level contains strategies that could be applied to all students with APD concerns; approximately 80% to 90% of students respond positively to these strategies and require no additional intervention. The targeted level addresses students who are at risk and who are not making expected academic progress. Supports at this level may be individual or group based and address 5% to 10% of the student population. The third tier provides the most intensive interventions to the remaining 1% to 5% of students. These interventions are individualized to the needs of each student, and the student’s progress is monitored frequently so that adjustments can be made or additional assessment conducted. Students with IEPs, Section 504 plans, and other learning supports are located throughout the tiers of this model based on each of their individual needs. The examples of interventions for students with APD at the universal and targeted levels may or may not be the result of an APD assessment. Assessment may only be necessary if these interventions are not providing sufficient supports for students to be successful in their educational programs. Issues with the MTSS model that need to be considered include the following:

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Step 2. Referral and Screening Referral and screening may begin with building awareness regarding typical behaviors associated with APD. Behaviors common in children with APD are listed in Table 6–1. Children rarely display all of these behaviors, but it is likely they will exhibit several of them.

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TABLE 6–1  Characteristics of Children With Auditory Processing Deficits Reported difficulties: ■■ Following or understanding speech …… In noisy situations …… In poor acoustical situations (e.g., reverberant) …… When the signal is fast or degraded (e.g., phone) …… In the absence of multisensory supports ■■ Localizing the source of a signal ■■ Comprehending messages that rely on tone of voice such as sarcasm or humor ■■ Singing or appreciating music (e.g., nursery rhymes) ■■ Learning new or complex languages Resulting in: ■■ Delayed, inconsistent, or inappropriate responses in oral communication situations ■■ Requests for repetitions (saying “huh” or “what” often) ■■ Trouble following complex auditory directions ■■ Inattention or distractibility in listening situations ■■ Poor performance on auditory-dependent multidisciplinary tests/subtests (e.g., receptive language, phonology) ■■ Associated academic difficulties in reading, spelling, and/or learning Note. From Colorado Department of Education, Exceptional Student Leadership Unit, Guidelines for Educational Evaluation and Intervention of Auditory Processing Deficits (2019 revision in process). Used with permission.

Chapter 6

Students are often referred by concerned parents or another member of the educational team, most often an SLP. Educational audiologists can use the list of behaviors provided in Table 6–1 to educate parents and teachers about auditory processing and APDs and to encourage the referral of children with listening difficulties for further consideration. The first step in this process must be a more formal hearing screening to rule out peripheral hearing loss. Once hearing loss is ruled out, the use of teacher and parent questionnaires can be used to address the child’s processing concerns. These questionnaires usually probe auditory behaviors related to academic achievement, listening skills, and communication. The use of questionnaires should be considered subjective with the purpose to gather observational data only. Available behavioral checklists include items that are not restricted to APD, and several studies have found no correlation between parent and teacher report on APD or listening questionnaires and diagnostic performance on APD tests. Appendix 6–A

Nuggets from the Field When examining behaviors and other reported concerns, it is helpful to differentiate whether they are primarily seen in the auditory modality compared with other modalities such as visual, tactile, and so on.

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includes a list of common questionnaires for APD. Audiologists often use these questionnaires as an initial part of the referral process to begin sorting out auditory-specific behaviors in relation to other areas of functioning. Questions that should be discussed as a result of this screening information are as follows: 1. What behaviors does the student exhibit which may be indicative of or associated with APD? 2. How is the student responding to intervention strategies? 3. Is further assessment warranted? Would it change the interventions for this student? If so, what domains (audiological, speech-language, cognitive, behavioral) should be assessed? 4. What factors need to be considered for further assessment (e.g., age, cognitive status, speech/language competence/English language proficiency, attention)?

Referral Considerations An important part of the APD assessment process is considering personal factors of the student being referred in order to determine appropriateness of the referral as well as val­ idity of auditory test results. Behavioral assessment of auditory processing requires a basic level of ability to participate in the assessment including being able to understand the task requirements. Audiologists are cautioned to use professional judgement for the following considerations and to clarify modifications in test procedures and/or interpretation of results in the report. ■■

Peripheral hearing: hearing acuity must be normal, or the child must be cleared by an audiologist prior to con-

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In addition to these referral considerations, the school team should consider current RtI/MTSS interventions and subsequent academic and behavioral performance results and data obtained by other team members. Based on this body of evidence, the team may decide to continue with RtI/MTSS interventions and progress monitoring or proceed with a referral for assessment. Assessment areas (e.g., speech-language, psychological, educational, or other) should also be determined at the time the referral is initiated. A sample referral form for APD assessment is in Appen­ dix 6–B. Use of a form such as this ensures that the referral process is well understood by all team members and that referral practices are consistent from team to team. It also helps to control the number of referrals by requiring a formal referral process.

Screening Having a plan or process in place at the screening level allows the audiologist and educational team to appropriately identify those students who would benefit from further diagnostic testing. Identifying which students are appropriate for screening and assessment should begin with a discussion of screening tools. Through the RtI/MTSS model, these screening tools might be used by any member of the school team. In addition to screening, general intervention suggestions can be made available to teachers for those students who might be suspected of having an APD. Screening tools, as discussed in this chapter, do not require parent permission because no procedure is being conducted with the student. APD screening tests include stand-alone screeners such as the Differential Screening Test for Processing (DSTP), which can be given by the audiologist, SLP, or another trained professional. Portions of several of the diagnostic APD assessments such as the MAPA-2, SCAN-3, and Feather Squadron contain screening subtests that can be used to determine whether additional diagnostic testing is warranted. In cases where questions arise from referral considerations (such as age, attention, etc.), use of a screening tool is useful in determining next steps. Appendix 6–D includes various APD screening tools.

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sidering testing for auditory processing. Some tests do allow for some accommodation for hearing loss; however, in general, loss of audibility in the form of peripheral hearing loss will confound the already complex task of identification of APD in children and may not result in added value to an intervention plan. Age of the child: screening is generally most appropriate for children 3 to 6 years of age, assessment beginning at 7 or 8 years; age criteria recommended with each screening or assessment instrument should be followed. An age criterion is important as it reflects the developmental component of the central auditory pathways and resulting developmental abilities of the child. There is some disagreement among professionals whether children under the age of 7 years should be assessed for APD. While there are APD assessments available for younger ages, interpretation of the results using a multidisciplinary approach may not be readily accessible. Screening instruments or observation tools may be more appropriate for young children with potential auditory processing problems and may guide the use of intervention strategies and future assessment recommendations. Cognitive ability: formal assessments of central auditory processing are normed on individuals who have cognitive ability within a normal range; the assessments impose varying degrees of cognitive load during the testing (e.g., on working memory and attention). Students suspected of having certain cognitive deficits may be considered candidates for an auditory processing assessment after careful consideration by the audiologist. In order to rule out or to identify scattered weaknesses, a cognitive assessment is highly recommended prior to the consideration of an APD referral. Language competence: language skills can significantly impact performance on auditory processing tasks, particularly those which require higher-level language processing. Results must be interpreted carefully, and extra caution is recommended with nonnative Englishspeaking students. Comorbid conditions: children with auditory processing deficits share many behavioral characteristics with other conditions, particularly ADD/ADHD, language disorders, and learning disabilities. While these conditions may coexist, the auditory processing problem is not the result of these problems (ASHA, 2005). It is important to try to sort out the behaviors associated with these conditions so that an accurate diagnosis can be made and to ensure the interventions are targeted to the problem and analyzed for their impact on the auditory processing problem. Speech intelligibility: significant speech intelligibility problems can affect administration and interpretation of auditory processing test results. If reasonable accommodations cannot be implemented, auditory processing assessment may not be appropriate until a later time.

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Step 3. Assessment for APD Setting up the assessment portion of the APD program includes several components including the case history, development of an assessment protocol, test administration considerations, and test interpretation.

Case History As with the assessment of any hearing condition, the assessment of APD should begin with a complete case history. The history will help the educational audiologist focus on the immediate concerns of the parents and the teachers, will provide information that will supplement the more formal audiometric tests, and will prove invaluable in determining

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recommendations concerning the child’s educational management. Although many of the questions in the history interview will be similar to those discussed in Chapter 5, Assessment, the educational audiologist should also obtain information on the child/youth’s communication, listening and auditory behavior, psychological factors, social background, educational achievement, and current educational and therapy services. Appendix 6–C contains a sample case history form.

Developing an Audiological APD Assessment Protocol There are many audiological tests that have been designed to test auditory processing skills. A test battery approach is necessary to assure that the full range of auditory processes is evaluated across the regions and levels within the CANS so that deficits and patterns of deficits can be identified. The ASHA practice portal outlines the following principles that must be considered when developing an assessment protocol. ■■

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The test battery process should not be test driven; rather, it should be motivated by the referring complaint(s) and the relevant information available to the audiologist. A central auditory test battery should include measures that are sensitive to the integrity of the CANS. Tests should examine different central processes, tasks, and the integrity of multiple levels and regions of the CANS. Most available behavioral central auditory tests are more appropriate for administration to children 7 years of age and older due to the challenging nature of the tasks and considerable performance variability. Communication checklists, language tests, and cognitive tests can be used to identify younger children that may be “at risk” for auditory difficulties (Moore et al., 2013). A diagnosis should be withheld until formal testing can be completed.  Tests should generally include both nonverbal and verbal stimuli to examine different aspects of auditory processing and different levels of the auditory nervous system. Individuals who are medicated successfully for attention, anxiety, or other disorders that may confound test performance should be tested under the influence of their medication. Neuromaturation, subject state, and cognitive factors may affect the outcomes of many electrophysiologic procedures when used with children younger than 10 years of age. These measures need to be administered and interpreted accordingly. The duration of the test session should be appropriate to the individual’s attention, motivation, and energy level. As with all behavioral tests, it is important to monitor the individual’s level of attention and effort and to take steps to maintain motivation throughout testing. Referral to the appropriate professional(s) should be made when there is a suspected speech or language impairment or intellectual, psychological, or another defi-

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cit. In some cases, this referral should precede CAP testing to ensure accurate interpretation of test results. Comorbid diagnoses may preclude CAP testing (e.g., significant intellectual deficit, severe hearing loss). Test findings should be corroborated by relating them to the individual’s primary symptoms or complaints (e.g., difficulty hearing with the left ear versus the right ear, difficulty understanding rapid speakers, difficulty hearing in the presence of competing noise).

Assessments that test central auditory processing skills are either behavioral or electrophysiologic. Behavioral tests are the primary type of tests available in the school setting and are the most helpful for assessing functional capabilities of the auditory system. Typically, behavioral tests are organized by the type of test or method of administration (monaural, dichotic, etc.), and best practices suggest using a variety of tests to assess multiple areas of auditory processing. A simplified approach, as pictured in Figure 6–2, categorizes APD assessments into three processing or skill areas: binaural, temporal, and speech (Colorado Department of Education, 2019; Rawool, 2016, 2018). Binaural Processing Tests  Binaural tests examine and compare the interaction between left and right ears. Binaural tests may include speech or nonspeech stimuli and assess aspects of spatial hearing such as sound localization and lateralization. The most commonly used binaural tests assess dichotic listening—or listening to different information being presented to each ear simultaneously. Dichotic listening skills are important when listening in noisy environments or when auditory distractions are present. The listener must be able to put the stimuli from two ears together (integrate) or ignore one ear while listening to the other (separate). Dichotic tests assess various levels of the central auditory nervous system (CANS) as well as cortical and corpus cal­ losum functioning. Temporal Processing Tests  Temporal tests use nonspeech stimuli to examine the CANS’ ability to recognize both

Nuggets from the Field Organizing and administering tests by processing domain can help to clearly identify specific deficit areas, relate them to behavioral indicators, and aid in the recommendation of deficit-specific interventions.

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timing and sequencing of auditory stimuli. Gap detection tests assess temporal resolution, and patterning tests (pitch and duration) assess ordering/sequencing of auditory stimuli. Pitch pattern tests also assess frequency discrimination. Temporal processing skills underlie almost every aspect of listening as analyzing acoustic events happens within a time window and contributes greatly to perception of rhythm, stress, and intonation, the prosodic (nonverbal) aspects of speech. Speech Processing Tests  Speech tests ask the listener to perceive words and sentences that are not quite clear. Speechin-noise tests add varying types and levels of background noise to the stimulus and may be administered to one (mon­ aural) or both ears under headphones or in the sound field. Many of these tests were not necessarily developed to assess the integrity of the CANS; however, they are useful, normreferenced tools to examine auditory figure-ground skills, which are important for listening in the classroom. Other speech tests feature degraded speech, where a portion of the word has been filtered out or the sentence has been time compressed, and these assess auditory closure skills. Speech tests are more linguistically “loaded” than the other types of auditory tests and are therefore highly dependent on the listener’s language abilities.

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Table 6–2 provides a summary of common behavioral assessments used for APD evaluation organized within this processing domain framework. This list is not exhaustive, and audiologists should update such a list as new tests become available. It is not expected that educational audiologists have all assessments listed but rather that there are sufficient tests to assess each of the skill areas. Many of the most widely used APD assessments come within a battery of tests such as the SCAN-3 and the MAPA-2. A new APD assessment, Acoustic Pioneer’s Feather Squadron, is administered via an iPad app that presents assessments through a game format that is quick and motivating for students. Resources for purchasing assessment materials are provided in Appendix 6–D. Electrophysiological tests of auditory evoked responses (AERs) from the auditory brainstem response (ABR) are not readily available in educational settings but may be accessed through university or hospital audiology clinics and centers when additional information is needed. These assessments may provide information about the integrity of the central auditory system through examination of the neuromaturation and neuroplasticity of the central auditory pathways. The application of using electrophysiological assessments in APD assessment is an ongoing area of investigation and not routinely used outside of the research setting.

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FIGURE 6–2  Auditory processing domains. (Adapted from Rawool, 2018; Colorado Department of Education, Exceptional Student Leadership Unit, Guidelines for educational evaluation and intervention of auditory processing deficits [2019 revision in process]. Used with permission.)

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TABLE 6–2  Summary of Common Behavioral Audiological Tests of Auditory Processing BINAURAL Processing Tests Dichotic Sounds

Competing Environmental Sounds Test (Precision Acoustics) Feather Squadron: Dichotic Single and Double Sounds (Acoustic Pioneer)

Dichotic Digits

Dichotic Digits (Auditec, MAPA-2) Feather Squadron: Dichotic Double Words (Digits) Subtest (Acoustic Pioneer)

Dichotic CVs

Dichotic Consonant Vowel Test (Auditec)

Dichotic Words

Staggered Spondaic Words “SSW” (Precision Acoustics) SCAN-3: Competing Words Free Recall and Directed Ear Subtests (Pearson, Auditec) Feather Squadron: Dichotic Words (Colors) Subtest (Acoustic Pioneer) Dichotic Word Listening Test (Auditec)

Dichotic Sentences

Competing Sentences (SCAN-3; Auditec, MAPA-2) Dichotic Sentence Identification Test (Auditec)

Localization, Lateralization, and Interaction

Listening in Spacialized Noise–Sentences Test “LiSN-S” (Phonak) Feather Squadron: Speech in Noise with Localization Cues Subtest (Acoustic Pioneer) Feather Squadron: Lateralization Subtest (Acoustic Pioneer) Masking Level Difference “MLD” (Auditec) TEMPORAL Processing Tests

Gap Detection

Random Gap Detection (Auditec) Gaps in Noise (Auditec) SCAN-3: Gap Detection Screening (Pearson, Auditec) Feather Squadron: Rapid Tones Subtest (Acoustic Pioneer)

Frequency and Duration Patterns

Frequency (Pitch) Patterns (Auditec, MAPA-2, Pro-Ed/DSTP) Feather Squadron: Tonal-Pattern and Rapid Tones Subtests (Auditec) Duration Patterns (Auditec, MAPA-2) SPEECH Processing Tests SCAN 3: Auditory Figure Ground Subtests (0, 8, 12 dB) (Pearson, Auditec) Feather Squadron: Speech-in-Noise Subtest (Acoustic Pioneer) Pediatric Speech Intelligibility Test “PSI” (Auditec) W-22 in Noise (Precision Acoustics) Words in Noise Test “WIN” (Auditec) QUICK and BKB-SIN (Auditec) Selective Auditory Attention Test “SAAT” (Auditec) Monaural-Selective Attention Test (MAPA-2) Speech-in-Noise for Children (MAPA-2) Auditory Discrimination (Pro-Ed/DSTP)

Filtered Speech

NU-6 Low Pass Filtered Speech (Auditec) SCAN 3: Low Pass Filtered Speech Subtest (Pearson, Auditec)

Time Compressed Speech

Feather Squadron: Rapid Speech Subtest (Acoustic Pioneer) SCAN 3: Time Compressed Sentences Subtest (Pearson, Auditec) NU-6 Time Compressed (30% and 60%) (Auditec) NU-6 Time Compressed + Reverberation (Auditec) Time Compressed Sentence Test (Auditec)

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Speech-in-Noise

Note. Adapted from Colorado Department of Education, Exceptional Student Leadership Unit, Guidelines for educational evaluation and intervention of auditory processing deficits (2019 revision in process). Used with permission.

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Prior to administering APD assessments, an evaluation of peripheral hearing should be performed including pure-tone, speech, and electroacoustic tests. Ruling out peripheral hearing problems assures that behavioral complaints are not a result of undiagnosed hearing loss of some type. Once the assessments of the APD protocol are established, the audiologist then selects specific tests within each processing area based on the age and presenting concerns of the child/youth being assessed. In addition, the following areas should be considered: ■■

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Validity and reliability: norms for tests used must be reviewed and considered. Caution must be used in interpretation since some of the measures have limited normative data for children and may require that local norms be developed. Administration issues: ease of administration, administration time, availability of needed equipment, and the acoustic environment may dictate which assessments are used. Test interpretation and scoring: test manual procedures and interpretation must be adhered to and considered along with the results of the multidisciplinary assessment. Motivation, fatigue, and emotional status: significant test variability can occur based on these factors; when either is suspected, repeat assessment may be necessary to determine the reliability of the test responses. Attention and/or distractibility: in addition to the same considerations for motivation and emotional status, test modifications may be necessary to ensure that the student is attending for each test item; any test modification should be noted on the protocol and must be taken into consideration in the test interpretation. Multidisciplinary assessment: auditory processing assessment should not occur in isolation from other speech-language, psychoeducational, or other evaluation.

APD Assessment in Atypical Populations Young Children  Some tests for assessing auditory process­ ing skills provide normative data for children as young as 3 years of age. Because of the extreme variability of normal auditory development in children below the age of 7 years, young children who are suspected of having an APD often score within the normal range on these tests. As a result, it may be difficult to diagnose APD adequately in children younger than 7 years. When asked to determine if a young child has an auditory processing problem, the educational audiologist can administer one or more of the tests that have age-appropriate normative data, but the possibility of identifying an APD should not be ruled out if the test results are normal. If the parents and/or teacher have strong concerns about the child’s auditory skills, it is advantageous

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to provide management recommendations based on the behavioral characteristics of the child and to monitor the child’s behavior frequently in response to them. If concerns continue, assessment should be completed when the child reaches age 7 years. Non-English-Speaking Children  Several tests have been standardized in other languages. However, there are often significant language differences when those tests are used in the United States. It is therefore best to use tests with nonverbal stimuli when assessing the auditory processing skills of children who have limited proficiency in English. The results of these tests may not provide a complete auditory processing assessment, but they may provide information useful in documenting and managing the child’s listening difficulties. Children With Peripheral Hearing Differences  Most of the auditory processing tests are not normed for admin­istration to children with peripheral hearing losses, making it difficult to assess the auditory processing skills of these children. In cases of mild, or mild to moderate, reduced hearing levels with similar thresholds across frequencies, the educational audiologist can administer tests that are not significantly affected by peripheral hearing loss. The Dichotic Sentence Identification (DSI), a modification of the Synthetic Sentence Identification (SSI), contains norms for individuals with hearing loss. Dichotic digits and pitch and duration pattern tests may also be useful. For unilateral hearing loss, it is possible to administer monaural tests to the normal hearing ear. The experienced clinician may be able to infer information about the student’s processing skills by looking at the results of monotic tone tests obtained at frequencies when the hearing sensitivity is normal or by looking for asymmetries in results of the two ears when the peripheral hearing loss is symmetrical. It must be recognized that the assessment provided for students with reduced peripheral hearing will be incomplete, but the information obtained can assist in doc­ umenting auditory problems in addition to the peripheral hear­ ing status and can lead to improved management of the child’s auditory problems.

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Supplemental and Multidisciplinary Tests of Auditory Processing  When necessary, the audiologist may incor­ porate several additional tests to supplement the APD bat­ tery. The areas of attention and auditory memory are worth noting because they should be part of the APD protocol. Typically, attention abilities are examined from a behavioral perspective and most often by the school psychologist using parent and teacher questionnaires. The audiologist, however, may choose to use the Auditory Continuous Per­ formance Test (ACPT) to examine attention specific to the auditory modality. Likewise, auditory memory is often exam­ ined from a cognitive or linguistic perspective by the psy­ chologist or SLP; however, several subtests of the TAPS-4

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Nuggets from the Field The purpose of a cognitive evaluation in APD assessment is generally not to obtain a formal IQ score. Cognitive evaluations instead offer valuable information into other processing areas such as visual, nonverbal, and working memory, which is crucial in the interpretation of the audiologist’s APD assessment.

do the same and may be given by the audiologist instead. If reading concerns are present, it is imperative to assess phonemic and phonological skills that can be done with a variety of tests by a variety of professionals. Regardless of which professional conducts the assessment, multidis­ ciplinary tests should be chosen based on the refer­ring complaints. Appendix 6–E contains a list of common lin­guistic, cognitive, and educational assessments for this purpose.

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Observation of the Student  A final consideration for test administration is the opportunity for observation of the student in their classroom or customary environment. During formal assessment, we observe the student’s beha­viors. Although this observation is done in a very structured situation, it may provide clues to why the student is having difficulty in the classroom and may lead to suggestions for classroom management. In addition, the educational audiologist will find it helpful to observe the student in the classroom and other settings when this is possible. This obser­vation can be structured with the use of questionnaires such as the Children’s Auditory Performance Scale (CHAPS) (Smoski, Brunt, & Tannahill, 1998). Behaviors the educational audiologist should observe include ■■

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Nuggets from the Field Qualitative information from a classroom observation can be as informative as the test scores themselves and may fill in gaps about a student when test administration is compromised due to attention, motivation, and other behavioral factors.

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listening in noise and distance conditions as well as without visual access to the speaker (consider a Functional Listening Evaluation “FLE,” see Appendix 5–H); cooperation and willingness to perform both easy and difficult tasks; response to frustration; need for praise and encouragement in order to complete a task; and acoustic characteristics of the listening and learning environments.

Test Interpretation As stated previously, ASHA (2018) recommends that the criteria for an AP disorder be determined based on test performance that is at least two standard deviations below the mean on two or more tests of the battery or that the performance on one test is three standard deviations or more below the mean when the performance is accompanied by significant functional difficulty. In the latter situation, it is also important to reassess the area in question to rule out attention and other confounding variables that might have influenced test performance. Therefore, assessment results meeting one of these requirements lead to the identification of an AP disorder. Consideration of the results of all disciplines involved in the assessment is also critical to test interpretation and overall functional status of the student. The sample APD profile located in Figure 6–3 provides an illustrative method for quantifying and analyzing test performance across these domains (Appendix 6–F contains a blank form). In addition to the test results that show the student’s strengths and weak areas, the visual representation helps ensure that all areas have been evaluated and that sufficient information is available to respond to eligibility determination. For the student represented in this case, the profile shows significant AP issues confounded by attention deficits, phonemic delays and mild language delay, average to above average cognitive ability with significantly higher nonverbal skills, and academic deficits in reading and language. No emotional or social concerns were identified. As a result of the assessment, the following questions should be discussed: 1. Based on the multidisciplinary assessment, what are the student’s strengths and needs related to listening? 2. Does the severity of the deficits qualify this student for special education? 3. What are the specific characteristics of the AP deficit? 4. What are the services and accommodations that might be needed by this student (for special education eligible students, determination of services is made by the IEP team)? 5. What are the specific interventions recommended for this student (e.g., classroom management, accommodations including hearing assistance technology, instructional modifications, direct speech-language services)?

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Auditory Processing Deficits

FIGURE 6–3  Sample auditory processing assessment profile.

APD Profiles  A popular method of analyzing the AP results is through patterns of deficits. Models have been developed by Bellis and Ferre (Bellis, 2003), Katz, Smith, and Kurpita (1992), and Medwetsky (2002), among others. The purpose of these profiles is to aid in the interpretation of auditory processing and related assesments in order to facilitate development of an individualized, comprehensive, management plan that addresses the student’s functional deficits. While some student performance profiles will fit neatly into these models, many will not, making it challenging for the audiologist to interpret test results when using the profiling method. An alternate, simplified approach to

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interpretation is to examine test results within each of the processing areas and look for patterns of deficits that indicate weaknesses within that area. This type of analysis will allow for deficit-specific interventions to be implemented as well as to help parents and other professionals better understand the complexitites of central auditory processing.

Step 4. Eligibility for Services Eligibility is a two-part consideration: first, is there evidence of an auditory processing deficit, and second, does it cause

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IDEA Eligibility Categories for Students With APD Specific learning disability [34CFR300.8(10)] (i) General. The term means a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or to do mathematical calculations, including conditions such as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia, and developmental aphasia. (ii) Disorders not included. The term does not include learning problems that are primarily the result of visual, hear-

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an adverse effect on learning sufficient for the student to meet eligibility requirements for special education and related services. Since there is not a federal category of disability for auditory processing, part of eligibility also includes identifying the type of disability under which the student qualifies. In most states, the disability areas are either speech-language impairment (SLI) or specific learning disability (SLD). Recent court precedent has also indicated that the category of other health impairment (OHI), typically used for attention deficit disorders, can also include auditory processing deficits (McCarty, 2014). Members of the multidisciplinary team should be familiar with the criteria under each category, as well as recommended practices within their state, in order to make the most appropriate determination. Parents should also be aware of these categories so that they understand how AP applies within them. See the Text Box for these IDEA 2004 federal definitions. Once eligibility is determined, development of the IEP is completed by the IEP team for the student. Some children with auditory processing disorders or deficits may not demonstrate sufficient impact on educational performance to meet state eligibility requirements. In such cases, consideration of accommodations under Sec­ tion 504 (Rehabilitation Act of 1974) should be made. Sec­ tion 504 prohibits discrimination against any person with a disability, including students in public schools, if that program receives federal funds. The act defines a person with a disability as anyone who: Has a mental or physical impairment that substantially limits one or more major life activities (major life activi­ ties include activities such as caring for one’s self, per­ forming manual tasks, walking, seeing, hearing, speak­ ing, breathing, learning, and working).

Eligibility for Section 504 is established in a meeting that determines the condition and its impact on the student’s

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ing, or motor disabilities, of mental retardation, of emotional disturbance, or environmental, cultural, or economic disadvantage. Speech or language impairment [34CFR300.8(11)] means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance. Other health impairment [34 CFR 300.8(c)(9)] means a chronic or acute health problem that results in limited alertness with respect to the educational environment and that adversely affects a child’s education performance.

education, the areas where accommodations will be necessary to assist the student, and then a detailed list of the accommodations and services that will be provided. Appen­ dix 6–G contains a checklist of common accommodations and modifications for students with APD. This checklist can be attached to the IEP or the Section 504 plan. Plans should be reviewed periodically, but there are no specific requirements specifying review timelines (see Appendix 11–E for a sample Section 504 plan).

Step 5. Intervention The development of an APD program is not complete without provisions for intervention for the students who are identified. “The overall goal of intervention is to provide the individual with the ability to communicate more effectively in everyday contexts (e.g. home, classroom) . . . and requires an analysis of functional deficits and specific recommendations for change across settings” (ASHA, 2018). Intervention covers the broad category of services a student receives as part of their IEP or Section 504 plan as a result of an APD or other concurrent disorders affecting learning. Some of these services might also be provided as part of the RtI/ MTSS series of interventions. Intervention can be provided using two basic methods: (a) direct services delivered on an individual or small group basis to address auditory processing deficits from both a bottom-up (auditory skill building) and top-down (self-management and other compensatory skills) approach; and (b) indirect interventions designed to enhance the message or mitigate a poor listening environment. By considering the individual listener, the message, and the environment, an intervention plan can offer a holistic approach to managing APD in the school setting. For a comprehensive discussion of APD interventions, the reader is referred to Geffner and Ross-Swain’s Auditory processing disorders: Assessment, management, and treatment (2019).

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Direct activities and services should be targeted to those areas of deficit identified in the APD and multidisciplinary assessment. A “process-based” remediation plan will match specific activities such as dichotic listening training or temporal processing training to the areas of need identified in the APD assessment. In addition, if a student has identified weaknesses in higher-order skills related to accessing auditory information, direct services could include training in areas such as problem-solving, active listening, or vocabulary building. Typically, the SLP and/or special education teacher will provide most of the direct services identified through the IEP process. Many of the activities may be written as goals and objectives on the student’s IEP and thereby be closely monitored for progress and effectiveness. Audiologists may or may not provide direct services in the school setting, and which professional delivers the services will vary from school to school. Skill Building Activities (Bottom-Up) Skill-building activities seek to improve specific auditory skills by providing intensive repeated practice of the skills. This “auditory training” is based on the premises of brain plasticity and cortical reorganization. Training activities may be considered informal such as in the case of therapist-directed listening tasks, or formal such as with the growing selection of computerbased programs. Whether informal or formal, Musiek, Chermak, and Weihing (2007) identified several important principles of auditory training: ■■

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Materials need to be appropriate for age and language abilities of the students. Motivation needs to be developed and maintained through­out the training exercises. Tasks need to be varied to increase and broaden performance gains. Tasks should become increasingly difficult as a function of the student’s performance; the degree of increase should be monitored so that the steps are not too large to cause frustration yet large enough to push performance. Balance the success-failure rate so that the student continues to be motivated in the program. Make sure that there is sufficient time devoted to the training program to induce change. Provide the student with regular feedback regarding their progress. Monitor the program to ensure that progress is being made—auditory changes may be measured with psycho­ physical, electrophysiologic, and questionnaire methods. Maintain control of acoustic stimuli used in the training, and ensure that they are comfortable for the student (pp. 81–85).

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Computer-based auditory training programs are an effective way to meet the rigors necessary to affect change in the auditory system. These bottom-up auditory training activities are controlled and adaptive while also being fun for the student and easy to administer and track for the professional or parent. Students of all ages can work through a series of computer games designed to exercise their listening in those areas of auditory need identified in their APD assessment. Most programs are web-based and come with an associated cost. The growing availability of laptops and tablets in the classroom as well as the use of skill-building computer programs in general should increase the likelihood that schools can offer some of these specific listening programs for students identified with auditory processing deficits. For a brief description of current computer-based programs, see Appendix 6–H. Compensatory Strategies (Top-Down)  In order to in­­ crease the ability to access auditory instruction, students can benefit from being taught specific compensatory strategies to strengthen higher-order central resources (e.g., language, memory, and attention). Appropriate compensatory strategies should be identified for each student with APD, and when appropriate, the student should be involved in this discussion so that the student understands the problem and learns ways to help himself or herself. Training in these aspects can be considered formal and linked to specific IEP goals or may be informally taught such as during a study skills or resource class. Either way, students should be provided with structured practice in the understanding and use of which strategies are most helpful and in which environment. Compensatory strategies identified in the ASHA practice portal include metalinguistic and metacognitive strategies as well as language and curricular-based interventions. Following are a few examples that are designed as “topdown” supports for processing auditory information: ■■

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metalinguistic strategies include use of graphic organizers, phonological awareness, context to build vocabulary and active listening techniques; metacognitive strategies include organization skills, memory techniques (mnemonics, mind mapping), problemsolving, and assertiveness training; and language and curricular interventions include language and vocabulary building specific to academic tasks or subjects, use of contextual and visual cues to support understanding and how to organize incoming spoken and written language to support processing needs.

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Indirect Interventions Indirect interventions in the form of accommodations increase the accessibility of the message as well as the environment. Indirect interventions may also be both bottom-up and top-down and generally fall under two categories: ■■ ■■

instructional strategies (top-down) and speech enhancement (bottom-up).

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Instructional Strategies (Top-Down)  One of the most common methods used by educational audiologists to help accommodate students with APD is providing special strategies to the teacher for delivering instruction. Quite often a list of suggested strategies is provided to the teacher as the only recommendation for a student with APD. Although the suggestions on the list are typically beneficial for the student, teachers are often overwhelmed by the number of suggestions and therefore do not consistently follow any of them. Since we know that recommendations are only as good as how well they are implemented, the educational audiologist should limit the number of classroom strategies or prioritize them to emphasize the most critical considerations. Once the teacher has incorporated these accommodations, others may be added if necessary. The educational audiologist should select the most beneficial accommodations based on the student’s APD testing and functional classroom performance. By giving the teacher only three or four suggestions from the list, the educational audiologist can structure the accommodations to benefit the student. Self-esteem is a critical part of accommodating a student, especially those with extra learning difficulties. (See Chapter 10, Supporting Wellness and Social-Emotional Competence, for more on this topic.) Encourage the teacher to be positive and supportive, to praise the student’s effort and successes, and to encourage participation in activities where the student has strengths and is expected to succeed.

Chapter 6

Speech Enhancement (Bottom-Up)  Two “bottom-up” meth­ ods to improve accessibility of the auditory signal are the use of RM (remote microphone) HATs and modifications to the acoustic environment. RM HAT often provides significant benefit to students with auditory processing deficits in dichotic listening and speech-in-noise. Because a common problem encountered by children with APD is difficulty understanding in noisy environments, any technology that improves the signalto-noise ratio has the possibility of benefiting the student.

RM systems including personal and classroom audio distribution systems (CADS) have been used to enhance students’ abilities to attend in the classroom and are important strategies to consider for children who have difficulty listening in noise. Any RM system should be provided for an initial trial period so that the student, teachers, and parents can assess the benefit in the classroom before permanent use of the technology is recommended. Additionally, if a RM system is recommended, the audiologist should use a system that delivers the teacher’s voice with minimal amplification. Newer RM systems also provide signal enhancement to improve speech understanding in small and large group listening by using advanced micro­phone technologies. Guidelines for candidacy, selection, fitting, and managing HATs are discussed fully in Chapter 8, including protocols for assessing benefit. The AAA Clinical practice guidelines: Remote microphone hearing assistance technologies for children and youth from birth to 21 years (American Academy of Au­ diology, 2008) is an essential resource for fitting HATs on students with APD. As mentioned previously, it is often necessary to observe in the classroom to determine what should be done to improve the student’s classroom environment. If noise levels are a concern, the audiologist may also need to measure classroom noise levels and the reverberation time and make suggestions for change. (See Chapter 7, Classroom Acoustics and Other Learning Environment Considerations, for more information on this topic.) With the variety of interventions available for students with APD, it is often difficult to know which strategies will be most successful for which student. Quite often it is a combination of strategies that will be most beneficial. Unfortunately, the management of APD is often trial-and-error because the effects of specific recommendations are not known until they have been tried. It is therefore necessary for educational audiologists to work closely with teachers, parents, and service providers, as well as the students themselves, to monitor the success of interventions and to alter or implement other strategies when necessary.

SUMMARY It is obvious that diagnosis and management of students with APD is a perplexing task, but it is of great relevance to educational audiologists. Providing meaningful evaluation of APD takes time and requires a compilation of interprofessional practices. Figure 6–4 contains a flowchart that summarizes the collaboration in an educational APD assessment and intervention model. There is a great deal of information in the literature about APDs, often reflecting varying and contradicting viewpoints. This chapter has just skimmed the surface of APDs

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in emphasizing the most important points for educational audiologists when establishing programs. Further reading, attending workshops, and APD assessment experience will take the novice APD audiologist to a point of growing comfort and satisfaction with the APD program that has been designed. With your team of colleagues, it is important to constantly review the outcomes of the program you have established and make the necessary adjustments, especially as the body of knowledge of APDs continues to increase.

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Auditory Processing Deficits

FIGURE 6–4  Flowchart of educational model for auditory processing deficit assessment. (Colorado Department of Education, Exceptional Student Leadership Unit, Guidelines for educational evaluation and intervention of auditory processing deficits [2019 revision in process]. Used with permission.)

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SUGGESTED READINGS AND RESOURCES American Academy of Audiology. (2010, August). Diagnosis, treatment and management of children and adults with central auditory processing disorder [Clinical practice guidelines]. Retrieved from https://audiology-web.s3.amazonaws.com /migrated/CAPD%20Guidelines%208-2010.pdf_539952af95 6c79.73897613.pdf American Speech-Language-Hearing Association. (n.d.). Cen­ tral auditory processing disorder. (Practice portal). Retrieved from https://www.asha.org/Practice-Portal/Clinical-Topics /Central-Auditory-Processing-Disorder/ Bellis, T. (2003). Assessment and management of centeral auditory processing disorders in the educational setting. Clifton Park, NY: Delmar Learning. British Society of Audiology. (2011). Practice guidance: An over­ view of current management of auditory processing disorder (APD).  Seafield, Bathgate, Westlothian, Scotland: Author. Retrieved from http://www.thebsa.org.uk/wp-content/uploads /2017/04/APD-Position-Statement-Practice-Guidance-APD -2017.pdf

Canadian Interorganizational Steering Group for Audiology and Speech-Language Pathology. (2012, December). Canadian guide­ lines on auditory processing disorder in children and adults: Assessment and intervention. Retrieved from https://www .sac-oac.ca/sites/default/files/resources/Canadian-Guidelines -on-Auditory-Processing-Disorder-in-Children-and-Adults -English-2012.pdf Chermak, G., & Musiek, F. (2014). handbook of (central) auditory processing disorder (Vol. 2). San Diego, CA: Plural Publishing. Colorado Department of Education. (2008). (Central) auditory pro­ cessing deficits: A team approach to screening, assessment and intervention practices. Exceptional Student Leadership Unit. Denver, CO: Colorado Department of Education. Retrieved from https://www.cde.state.co.us/sites/default/files/documents /cdesped/download/pdf/apdguidelines.pdf Geffner, D., & Ross-Swain, D. (2019). Auditory processing disor­ ders: Assessment, management, and treatment (3rd ed.). San Diego, CA: Plural Publishing. Musiek, F., & Chermak, G. (2014). Handbook of (central) auditory processing disorder (Vol. 1). San Diego, CA: Plural Publishing.

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APPENDIX

6–A

Auditory Processing Deficit Screening Questionnaires Screening for auditory processing deficits typically involves systematic observation of auditory behaviors related to academic achievement, listening skills, and communication. The following are questionnaires that have been suggested for use in identifying individuals who may be candidates for auditory processing evaluation.

sess specific behaviors that can be associated with auditory processing weaknesses. It is divided into six areas: Linguistic Organization, Decoding/Language Mechanics, Attention/Organization, Sensory/Motor, Social/Behavioral, and Auditory Processes. Index scores are used and compared to criterion-based cut-off scores.

Children’s Auditory Performance Scale (CHAPS)

Classroom Performance/Impact Questionnaire (Appendix F–3 of CDE Guidelines)

Fisher’s Auditory Problems Checklist Fisher, L. I. (1985). Educational Audiology Association, 11166 Huron Street, Suite #27, Denver, CO 80234 (800460-7322). https://edaud.org This checklist is used by educators and other school sup­­ port personnel to assist in identifying behaviors that characterize children as at risk for APD. It includes many components of auditory processing, including attention, auditory-visual integration, comprehension, figure-ground, and memory. A score is derived by multiplying by four each item not identified on this 25-item checklist. Normative data are available for kindergarten through sixth grade.

The Listening Inventory Geffner, Donna, PhD, & Ross-Swain, Deborah, EdD. (2006). Academic Therapy Publications, 20 Commercial Blvd., No­ vato, CA 94949 (800-422-7249). https://www.academicther apy.com This is an informal behavior observation completed by parents and teachers. It can be used as a starting point to determine the need for further testing and as a discussion tool. It consists of 103 statements (0 to 5-point scale) to as-

Massine, Donna. (2008). Colorado Department of Educa­ tion (Central) Auditory Processing Deficits: A Team Ap­ proach to Screening, Assessment & Intervention Practices. http://www.cde.state.co.us/cdesped/rs-edaudiology This is an informal checklist (available in this document) that may be used as a teacher questionnaire or interview. It takes into account a myriad of classroom concerns including listening/language processing, sustained attention, working memory, thinking/reasoning, academics, metacognition, task initiation, organization, time management, selfregulation, motor skills, and environmental conditions. It is designed to identify specific areas that may be impacting auditory access in the classroom.

Evaluation of Children’s Listening and Processing Skills (ECLiPS) Barry J. G., & Moore D. R. (2014) Evaluation of Children’s Listening and Processing Skills (ECLiPS). London, UK: MRC-T The ECLiPS is a 38-item questionnaire used to evaluate a wide range of listening difficulties in children. It was developed based on research regarding the nature of listening difficulties and the relationship to disorders of language, literacy, and social communication. The questionnaire looks at five factors: speech and auditory processing, language/ literacy/memory and attention, pragmatic and social skills, environmental and auditory sensitivity. 

Chapter 6

Smoski, W. J., PhD, Brunt, M. A., PhD, & Tanahil, J. C., PhD (1998). Educational Audiology Association, 700 McKnight Park Drive, Suite 708, Pittsburgh, PA 15237 (800-4607322). http://edaud.org This checklist is used by educators and parents to assess listening difficulties in children. Six listening conditions are assessed in this 36-item checklist, including noise, quiet, ideal, multiple inputs, auditory memory/sequencing, and auditory attention span. The observation assessment is done by comparing the student to a reference population of other children of similar age and background. Items are rated on a scale from +1 (less difficulty) to –5 (cannot function at all). This instrument can be used as a pre- and posttreatment evaluation.

Auditory Processing Domains Questionnaire (APDQ) O’Hara, B., & Mealings, K. (2018). Developing the Audi­ tory Processing Domains Questionnaire (APDQ): A differ­ ential screening tool for auditory processing disorder. Int J Audiol. 57(10), 764–775. https://edaud.org This is a 52-question checklist developed as a differential screening tool for auditory processing disorder. It is to be completed by parents and/or teachers to review and rate 199

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observations of students age 7 to 17 years in everyday listening skills. Three scales are presented that rate competent performance in hearing-auditory processing (AP), attention control (ATT), and cognitive-language skills (LD-NOS). It takes approximately 15 to 20 minutes to complete.

Note. Revised from Colorado Department of Education, Exceptional Student Leadership Unit, (Central) auditory processing deficits: A team approach to screening, assess­ ment and intervention practices, 2008. Reprinted with permission. http://www.cde.state.co.us/cdesped/rs-edaudiology

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APPENDIX

6–B Referral for Auditory Processing Assessment

Student Name Date of Birth

School Grade

Referred By

Date ID# Position

Sex

IEP Date Phone #

Name and Phone # of person with whom to schedule the appointment  When referring for an auditory processing assessment, the following must occur PRIOR to the assessment and should be considered only after the diagnostic evaluations have been conducted and examined. Please check and complete the following information. All information will be kept confidential. Feel free to attach any additional information that you think may be helpful. Thank you.

REFERRAL CRITERIA Please confirm ALL of the following:   The student has passed a hearing screening in the past year.   The student is 7 years of age or older.   The student is English proficient; APD assessments are normed on native English speakers.  The student has intelligible speech; if speech is not intelligible, it will be difficult to differentiate a production error from a processing error.   The student’s cognitive function (nonverbal scales) is within the average range.  The student has participated in at least two RtI interventions without measurable progress; or the student is already on an IEP but demonstrating limited progress.

REFERRAL CHECKLIST Chapter 6

All of the items below must be ATTACHED to this referral. Please do not submit until all items have been checked off.   APD Referral Checklist (this form)   Auditory checklist completed by the classroom teacher, special educator, and parent   Current speech/language assessment   Current educational assessment   Current psychological assessment   Current health history Please state specific referral concerns    Note. From Colorado Department of Education, Exceptional Student Leadership Unit, (Central) auditory processing deficits: A team approach to screening, assessment & intervention practices, 2008. Reprinted with permission. http://www.cde.state .co.us/cdesped/rs-edaudiology

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APPENDIX

6–C Auditory Processing Case History Date: ______________________

General History Student’s Name: Date of Birth: Age: Person completing form: Relationship to student:   Mother’s Name: Father’s Name:   Home Address: Phone:   City: State: Zip code: Email:   Languages spoken in the home:   Student’s primary language: Is the student right- or left-handed?   Please list the # and ages of student’s siblings:   Does anyone in the family (parents, siblings, aunts, uncles, etc.) have a similar problem? If yes, please describe   Has the student been seen in this department before? If yes, when?  

Educational Information

Chapter 6

Grade: School: Teacher or school contact:   Classroom type: traditional portable open pod   Is the student’s school performance: Above average Average Below average   Has student repeated a grade? Which grade(s)? Is student frequently absent from school?   Does the student struggle in any subjects? If yes, please list   Does the student excel in any subjects? If yes, please list   Does the student receive any special education services? If yes, what services?     Does the student have any learning problems? If yes, please explain       Does the student have any speech-language problems? _____ If yes, please explain    

Processing Concerns Does the student have a problem listening or understanding? _____ If yes, please describe the problem:          

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Auditory Processing Deficits

203

When was the problem first noticed?  What treatment has the student received for this problem?    What questions would you like answered about the student’s problem?    

Developmental/Medical History Please indicate if the student has experienced any of the following: ____ Premature Birth ____ Currently takes medication ____ Problems before, during or after birth ____ Known hearing problems ____ Hyperbilirubinemia/Jaundice ____ Speech-language difficulties ____ Bacterial Meningitis ____ Sensory Integration Issues ____ Congenital or perinatal infections ____ Autism Spectrum Disorder ____ Asphyxia/lack of oxygen at birth ____ Attention Deficit Hyperactivity Disorder ____ Mechanical ventilation ____ Syndromal abnormality ____ Head or neck abnormalities ____ Serious illness or accidents ____ Fetal Alcohol Syndrome ____ Ear problems (Including: infections, eardrum ____ Delays in development perforations, wax, drainage, ear pain) ____ Fever over 104 degrees ____ Ear surgeries (i.e. tubes, etc.)

If your child has experienced any of the above, please explain (include specific treatment and medications):    

Please indicate if the student exhibits any of the following: ____ Sensitive to loud sounds ____ Appears to be confused in noisy places ____ Easily upset by new situations ____ Difficulty following directions ____ Restless/problems sitting still ____ Hyperactive ____ Short attention span ____ Impulsive ____ Easily distracted ____ Daydreams ____ Forgetful ____ Asks for repetition ____ Reverses words, numbers or letters ____ Prefers to play with older children ____ Prefers to play with younger children ____ Prefers to play alone ____ Seeks attention ____ Disruptive or rowdy

Plural_Johnson_Ch06.indd 203

____ Temper tantrums ____ Shy ____ Anxious ____ Lacks self confidence ____ Lacks motivation ____ Uncooperative ____ Disobedient ____ Inappropriate social behavior ____ Does not complete assignments ____ Easily frustrated ____ Tires easily ____ Irritable ____ Dislikes school ____ Difficulty understanding the meaning of words ____ Difficulty learning new concepts ____ Difficulty with reading ____ Difficulty expressing idea

Chapter 6

Behaviors and Characteristics

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Please provide any additional information to help us understand the student’s strengths and challenges.        Note. From the Colorado Department of Education, Exceptional Student Leadership Unit, (Central) auditory processing deficits: A team approach to screening, assessment and intervention practices, 2008. Reprinted with permission. http://www .cdce.state.co.us/cdesped/rs-edaudiology

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APPENDIX

6–D Auditory Processing Assessment Resources

Feather Squadron is an iPad app designed to measure a range of auditory processing abilities. It was designed for children (from age 5 years) but is also normed and can be used for adults. A 5-minute parent or teacher screening is available, as well as an extended screening tool for a speech-language pathologist (SLP) or psychologist to use. An audiologist is required to administer the full diagnostic evaluation that takes about 30 minutes. Results of the assessment are automatically sent to a profile on the website where a professional report including recommendations can be viewed and downloaded. The test is automated based on student age, adaptive based on student performance, and includes up to 10 subtests that assess lateralization, temporal processing, dichotic listening, speech-in-noise, and degraded speech (time compressed) as well as auditory memory. The test is designed to be given in its entirety rather than by individual subtest. https://acousticpioneer.com

Academic Therapy Publications: Multiple Auditory Processing Assessment (MAPA-2) The MAPA-2 is a comprehensive assessment of auditory processing and listening skills for ages 7 to 14 years. It may be used as a screener to be followed by other behavioral or physiological tests, or it may be used for a preliminary diagnosis in the auditory area. The test is administered via CD and can be used in a clinical setting or a sound booth. The MAPA-2 includes eight different subtests in three domains (monaural, temporal, and binaural) along with the Scale of Auditory Behaviors, a 12-item parent- or teacher-completed questionnaire of listening behaviors. https://www.academic therapy.com

Auditec, Inc Auditec has produced quality recordings for the audiology community since 1972. Many of the earliest recorded APD tests as well as newer tests are offered in their catalog. In addition to individual test recordings pioneered by Dr. Frank Musiek, such as the dichotic digits and pitch patterns tests, Auditec also offers the MAPA-2 and the SCAN-3 as well as a recorded battery of several of the most widely used tests. Descriptions of each of the tests can be found on their website. https://auditec.com

Pearson Clinical: SCAN-3: C/A (Children/Adolescents and Adults) The SCAN-3 is a widely used battery of screening and diagnostic subtests offered in a version for children (5 to 12 years) and an adolescent/adult version (13+ years). The tests are offered on a CD and can be administered in a sound booth or with a portable audio device and headphones. Subtests include temporal (gap detection), binaural (dichotic), and speech (figure-ground, closure) processing tests, and the diagnostic tests offer standardized scores and percentile ranks. https://www.pearsonassessments.com

Phonak: Listening in Spatialized Noise— Sentences Test (LiSN-S) Developed by the National Acoustic Laboratories and distributed in the United States exclusively by Phonak, the LiSN-S is an adaptive, virtual-reality, speech test that measures speech perception ability in noisy environments. Importantly, it also measures the ability of children to use the spatial cues that normally help differentiate a target talker from distracting speech sounds. An inability to use this information has been found to be a leading cause of difficulty understanding speech in noisy environments, such as the classroom. https://www.phonakpro.com

Precision Acoustics: Central Test Battery (Katz) Also known as the Buffalo Battery, the subtests of the Central Test Battery include very well-known and widely used tests such as the SSW (Staggered Spondaic Words) and W-22 in noise. Developed by Dr. Jack Katz several decades ago, the SSW and other tests in this battery continue to be popular, especially with those who use the Buffalo Model of APD. http://precisionacoustics.org

Chapter 6

Acoustic Pioneer: Feather Squadron

Pro-Ed: Differential Screening Test for Processing (DSTP) The DSTP is a screening test designed to differentiate among the various levels of auditory and language processing and identifies areas for referral or further evaluation. The DSTP is a screening instrument to assist professionals in determining if additional diagnostic assessment is warranted

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and the specific areas of focus for further testing. The subtest areas of the DSTP represent the neurological continuum of processing acoustic stimuli. Critical skills are evaluated in three major levels: acoustic, acoustic-linguistic, and linguistic. https://www.proedinc.com

Note. Adapted from Colorado Department of Education, Exceptional Student Leadership Unit, Guidelines for edu­ cational evaluation and intervention of auditory processing deficits (2019 revision in process). Used with permission.

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APPENDIX

6–E

Supplemental and Multidisciplinary Tests of Auditory Processing Full understanding of the ramifications of APD for the individual requires a multidisciplinary assessment to determine the functional impact and to guide treatment and management of the condition and associated deficits. Cross-discipline analysis of APD results, with results from nonaudiological disciplines, may assist audiologists and related professionals in differen­ tially diagnosing APD from disorders having overlapping behavioral attributes (e.g., ADHD, language disorder, cognitive disorder, learning disorder) (ASHA, 2005). Included is a partial list of available assessments across a continuum of auditory processing.

LINGUISTIC AND PHONEMIC ASSESSMENTS Organized below by various auditory skill areas; most speech-language tests measure auditory-language, and higher-order components of auditory processing. Adapted from Geffner, D. S., & Ross-Swain, D. (Eds.). (2007). Auditory processing disorders: Assessment, management and treatment. San Diego, CA: Plural Publishing.

Auditory Perception and Discrimination ■■

■■ ■■ ■■

The Goldman-Fristoe-Woodcock Test of Auditory Discrimination (GFWTAD; Goldman, Fristoe, & Woodcock 2000) Subtests of Quiet and Selective Attention Lindamood Auditory Conceptualization Test, Third Edition (LAC-3; Lindamood & Lindamood, 2004) Test of Auditory Processing Skills, Third Edition (TAPS-4; Martin & Browness, 2005) Wepman’s Auditory Discrimination Test (Wepman & Reynolds, 1997)

Auditory Association/Receptive Vocabulary ■■ ■■ ■■ ■■ ■■ ■■

The Comprehensive Receptive and Expressive Vocabulary Test–Revised (CREVT-2; Wallace & Hammill, 2002) The Clinical Evaluation of Language Function, Fourth Edition (CELF-4; Semel et al., 2003) The Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk, 1994) The Peabody Picture Vocabulary Test (PPVT; Dunn & Dunn, 1997) The Receptive One-Word Picture Vocabulary Test (ROWPVT; Brownell, 2000) TOLD P:3 Subtest 1

■■ ■■

■■ ■■ ■■ ■■ ■■ ■■

The Auditory Processing Abilities Test (APAT; Ross-Swain & Long, 2004) Subtests 2, 6, and 9 CELF-4 Subtests of Understanding Concepts and Following Directions; Number Repetition; and Familiar Sequences, Recalling Sentences The Comprehensive Test of Phonological Processing (CTOPP; Wagner et al., 1999) Subtest 3 TOLD-P:3 Subtest 5 The Token Test for Children, Second Edition (TTFC-2; McGhee, Ehrer, & DiSimoni, 1978) TAPS-4 Subtests of Number Memory Forward; Number Memory Reversed; Word Memory and Sentence Memory Wepman’s Auditory Memory Battery (Wepman & Morency, 1985) The Wide Range Assessment of Memory and Learning – Second Edition (WRAML-2; Sheslow & Adams, 2003)

Chapter 6

Auditory Memory

Phonemic Awareness Skills ■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

APAT Subtest 1 CELF-4 Subtest of Phonological Awareness CTOPP Subtests 1, 2, 8, 10, 11, and 12 LAC-3 The Phonological Awareness Test (PAT) TOLD-P:3 TAPS-4 Subtests of Phonological Segmentation and Phonological Blending Phonemic Synthesis Test Subtest of Katz Central Test Battery

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Chapter 6

Auditory Closure Skills ■■ ■■

CASL Subtest of Meaning from Context Test of Language Competence (TLC; Wiig & Secrord, 1989) Subtest 3

Auditory Comprehension and Auditory Cohesion Skills ■■ ■■

■■

■■ ■■ ■■ ■■

APAT Subtests 7, 8, and 10 CELF-4 Subtests of Linguistic Concepts, Sentence Structure, Understanding Concepts and Following Directions, and Understanding Spoken Paragraphs CASL Subtests of Sentence Comprehension, Paragraph Comprehension, Nonliteral Language, Ambiguous Sentences, and Inference The Listening Test (Barrett et al., 1992) TAPS-4 Subtests of Auditory Comprehension and Auditory Reasoning TLC Subtests 1 and 4 WRAML-2 Subtests 1 and 6

Expressive Vocabulary Skills ■■ ■■ ■■ ■■ ■■ ■■ ■■

CREVT-2 CELF-4 Subtest of Expressive Vocabulary and Word Definitions The Detroit Test of Learning Abilities, Fourth Edition (DTLA-4) Subtest of Story Construction The Illinois Test of Psycholinguistic Abilities, Third Edition (ITPA-3; Hammill et al., 2001) Subtest 3 The Expressive One-Word Picture Vocabulary Test (EOWPVT; Browness et al., 2000) TOLD P:3 Subtest 3 The Expressive Vocabulary Test (EVT; Williams, 1997)

Word Retrieval Skills ■■ ■■ ■■ ■■ ■■ ■■ ■■

CELF-4 Subtests of Word Associations and Rapid Automatic Naming CASL Subtests of Antonyms, Synonyms, and Sentence Completion CTOPP Subtests 4, 6, 7, and 9 ITPA-3 Subtest 1 TOLD-P:3 Subtests 2 and 6 The Test of Word Finding, Second Edition (TOWF-3; German, 1999) The Boston Naming Test

Auditory/Speech Perception Under Degraded Listening Conditions ■■ ■■

GFWTAD Subtest of Selective Attention TAPS-4 Subtest of Auditory Figure-Ground

Chapter 6

COGNITIVE AND EXECUTIVE FUNCTION ASSESSMENTS Test patterns to consider are those observed deficiencies specific to the auditory modality. Those that are more pervasive in the overall functioning may suggest a more generalized cognitive or emotional challenge. ■■ WISC-IV (Wechsler Intelligence Scale for Children) ■■ DAS-II (Differential Ability Scales) ■■ WJ-III (Woodcock-Johnson III Tests of Cognitive Abilities) ■■ BASC-2 (Behavior Assessment System for Children) ■■ CRS-R (Conners’ Rating Scales, Revised) ■■ BRIEF (Behavior Rating Inventory of Executive Functioning) ■■ KABC-II (Kaufman Assessment Battery for Children) ■■ UNIT (Universal Nonverbal Intelligence Test) ■■ VMI (Beery Test of Visual Motor Integration) ■■ ACPT (Auditory Continuous Performance Test)

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Auditory Processing Deficits

209

EDUCATIONAL ASSESSMENTS Tests and measures specific to academic skills and current level of academic performance. ■■ ■■ ■■ ■■

WJ-III (Woodcock-Johnson III Tests of Achievement) Benchmark Tests (DRA, DIBELS, etc.) State Academic Standards Assessments District Assessments

Chapter 6

Note. Revised from Colorado Department of Education, Exceptional Student Leadership Unit, (Central) auditory processing deficits: A team approach to screening, assessment & intervention practices, 2008. Reprinted with permission. http://www .cde.state.co.us/cdesped/rs-edaudiology

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6–F

APPENDIX

Auditory Processing Assessment Profile Name: Auditory Acuity:

 Normal

 See Audiogram

DOB: Age: Acoustic Reflexes:

 Normal

Below Average Standard Deviation –3 Standard Score 1

3

55 Percentile Rank

4

–1 5

6

70 1

5

OAEs:

 Normal

Average

–2 2

 Abnormal

Date:

7

9

30

40

85 10

20

Above Average

0 8

10

+1 11

12

60

70

100 50

 Abnormal

13 14 115 80 90

+2 15

16

+3 17

18

130 95

19 145

99

ACOUSTIC:

LINGUISTIC:

Chapter 6 COGNITIVE:

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Auditory Processing Deficits Below Average Standard Deviation –3 Standard Score 1

Average

–2 2

3

55 Percentile Rank

4

–1 5

6

70 1

5

7

8

9

85 10

20

Above Average

0 10

+1 11

12

100 30

40

50

13

+2 14

115 60

70

80

15

16

+3 17

18

130 90

95

19 145

99

SOCIAL/: EMOTIONAL EDUCATIONAL:

OBSERVATIONS/COMMENTS:

Chapter 6

Note. © C.D. Johnson 2002. Updated 2019. Revised from Colorado Department of Education, Exceptional Student Leadership Unit, (Central) auditory processing deficits: A team approach to screening, assessment and intervention practices, 2008. Reprinted with permission. http://www.cde.state.co.us/cdesped/rs-edaudiology

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APPENDIX

6–G Accommodations and Modifications Checklist for Auditory Processing Deficits

NAME

DOB

DATE 

SCHOOL

ID

GRADE 

The following accommodations and modifications are recommended for this student to improve access to auditory information and are specific to the student’s APD profile. Accommodations are in regular print; modifications are italicized.

ENVIRONMENT ‰‰ Quiet, acoustically appropriate classroom ‰‰ Reduce/minimize distractions: Visual ______ Auditory ________ Spatial ______ Movement _______ ‰‰ Appropriate seating

PACING ‰‰ Decrease rate of speaking and delivery of instructions; use pauses before and after important points, emphasize critical information ‰‰ Extend time requirements for processing, responding and task completion ‰‰ Send school text, materials home for preview/review

PRESENTATION OF MATERIALS

Chapter 6

‰‰ Obtain student’s attention prior to delivery of information ‰‰ Monitor student for fatigue/length of attending time; provide breaks if necessary ‰‰ Present demonstrations (model) ‰‰ Utilize manipulative/hands-on instruction ‰‰ Pre-teach vocabulary ‰‰ Use visual sequences/pictorial directions ‰‰ Use outlines, overheads, graphic highlighting, organizers (e.g., highly structured) ‰‰ Provide animated, expressive teaching ‰‰ Repeat; do NOT rephrase information ‰‰ Rephrase; do NOT repeat information

ASSIGNMENTS ‰‰ Give directions in small, distinct steps ‰‰ Use written back-up for oral directions ‰‰ Give extra cues or prompts ‰‰ Adapt worksheets, packets according to student’s capabilities

MATERIALS ‰‰ Use supplementary materials ‰‰ Provide note taking assistance; copy of notes from another student

SELF-MANAGEMENT/FOLLOW-THROUGH ‰‰ Use visual daily schedule and calendars ‰‰ Train students to “look and listen” ‰‰ Check often for understanding/review ‰‰ Have student repeat directions ‰‰ Use study sheets to organize material ‰‰ Design/write/use long-term assignment timelines ‰‰ External organizational aids (e.g., lists, outlines, planners)

TESTING ADAPTATIONS ‰‰ Use pictures ‰‰ Read test to student ‰‰ Paraphrase instructions and test items ‰‰ Preview language of test questions ‰‰ Administer test by resource person ‰‰ Extend time frame ‰‰ Vary amount to be tested ‰‰ Vary grading system ‰‰ Vary response expectations

SOCIAL INTERACTION SUPPORT ‰‰ Provide peer partners ‰‰ Incorporate cooperative learning group ‰‰ Utilize home-school communication notebook

HEARING ASSISTANCE TECHNOLOGY ‰‰ Use personal system _________________ ‰‰ Use classroom system ________________

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Auditory Processing Deficits

OTHER STRATEGIES 

Note. From Colorado Department of Education, Exceptional Student Leadership Unit, (Central) auditory processing deficits: A team approach to screening, assessment & inter­ vention practices, 2008. Reprinted with permission. http:// www.cde.state.co.us/cdesped/rs-edaudiology

Chapter 6



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6–H

APPENDIX

Computer-Based Auditory Training Programs Computer-mediated auditory training programs are growing in popularity and have many advantages. They are convenient, they hold the interest of young children, there is a standardization of control of the stimulus, and the programs are adaptive. Thus, the stimulus or level may change based on the child’s correct or incorrect response. It is important to recognize the individual’s specific auditory deficit(s) and remember that no one single program will target every underlying auditory processing skill. New programs are introduced to the market continuously, so it is important for the clinician to be aware of new additions. Below is a brief description of some current programs available (see for a list and sources).

Chapter 6

Program

Source

Acoustic Pioneer

Acoustic Pioneer http://acousticpioneer.com/home1.html

BrainTrain

BrainTrain, Inc. http://www.braintrain.com

CAPDOTS

The Listening Academy, Inc. http://capdots.com

Earobics

Houghton, Mifflin, Harcourt http://www.hmhco.com/shop/education-curriculum/intervention/reading/earobics

Fast ForWord

Scientific Learning http://www.scilearn.com/products/fast-forword

HearBuilders

Super Duper Publications http://www.hearbuilder.com

Laureate Learning Systems

Laureate http://www.laureatelearning.com

LiSN and Learn

National Acoustics Laboratory http://shop.nal.gov.au/store/lisn-learn.html

Sound Auditory Training

Plural Publishing http://pluralpublishing.com/publication_sat

Acoustic Pioneer Another web-based program specifically designed for individuals with auditory processing concerns is Acoustic Pioneer. Acoustic Pioneer incorporates a diagnostic component along with direct intervention to address temporal processing, nonlinguistic auditory memory, nonlinguistic dichotic ability, rapid tonal processing, linguistic auditory memory, linguistic dichotic ability, time-compressed degraded speech, and speech-in-noise. Activities to address these areas are presented in animated games and increase in complexity as the individual progresses.

Brain Train Brain Train is another software program useful in aiding underlying language-processing skills, such as attention, sequenc­ ing, processing speed, and memory. Efficacy studies of this product have been limited to children with ADHD. This program is designed for patients age 6 years to adult.

CAPDOTS CAPDOTS (The Listening Academy) is an online auditory training program that focuses on dichotic training. CAPDOTS Integrated emphasizes exercises to improve binaural integration deficits. For these tasks, varied information presented to each 214

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215

hear must be interpreted and repeated. CAPDOTS Selected incorporates exercises to improve binaural separation skill that require interpreting information presented to one ear while disregarding auditory input into the opposite ear. Training can be started in children as young as 5 years of age.

Earobics The Earobics family of software products are another popular program for improving phonemic awareness, auditory process­ ing, and phonics, as well as cognitive and language skills that may benefit auditory and listening comprehension. Earobics is available for home, clinic, and school use. It is available in three levels—prekindergarten, school age, and adolescents and adults.

Fast ForWord Fast ForWord (FFW) is one popular software program based on the underlying temporal processing research of Tallal et al. (1996) and Merzenich et al. (1996). The Fast ForWord program is designed to develop temporal and acoustic skills to detect rapid transitions of speech. The exercises in the Fast ForWord program use acoustically modified speech. It is important to note an individual may not fit into one particular profile and may have characteristics of more than one profile or subtype. For this reason, some clinicians will focus rehabilitation efforts on the specific areas of auditory weakness. In the beginning of the program, the exercises prolong and emphasize the sounds and are easier to distinguish. As the listener progresses, speech sounds approach the rate of normal speech. As the listener improves, the exercises become more challenging, and the participant develops enhanced language awareness and comprehension.

HearBuilders HearBuilders incorporates multilevel activities centered around specific auditory language objectives for following directions, phonological awareness, auditory memory, and sequencing. Tasks increase in complexity from visual with auditory to auditory alone. The program is appropriate for pre-K through eighth grade.

Laureate Learning Systems The Laureate Learning Systems include programs that address language-processing skills. The programs contain exercises for preverbal children up to adults. Exercises include categorization and syntax training, auditory discrimination, reading, and spelling.

LiSN and Learn

Sound Auditory Training Sound Auditory Training (SAT) is an auditory training program designed to address a variety of auditory skills. Preformatted auditory tasks train in the areas of intensity, frequency, and temporal discrimination, identification, and recognition, gap detection and identification, frequency and duration pattern recognition, binaural interaction (500 Hz tone or speech), speech recognition in noise, and dichotic listening. It is specifically designed for children and adults with auditory processing disorders.

Chapter 6

The LiSN and Learn computer-based program is specifically designed to help improve the perception of speech in the presence of background noise. A three-dimensional auditory environment is produced under headphones where speech is spatially separated in noise. The tasks are presented in a game-like format where the child identifies a target word from a sentence.

Other Programs Several other computer-mediated programs have been developed for individuals with hearing loss. These programs are appropriate for a wide variety of ages, from preschoolers through adults, and include exercises in sound identification, auditory discrimination, and speech-in-noise training. New software programs targeting AP skills are continuously introduced into the market. Clinicians need to routinely search for new product launches to remain current. Note. From McNamara, T. L., & Hurley, A. E. (2017). Diagnosis and treatment of auditory processing disorders: A collab­ orative approach. In D. R. Welling & C. A. Ukstins (Eds.), Fundamentals of audiology for the speech-language pathologist (pp. 439–463). Burlington, MA: Jones & Bartlett Learning. Used with permission.

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APPENDIX

6–I Instructional Interventions for Students With Auditory Processing Deficits

Instructional Interventions Instructional accommodations consist of purposeful adaptations made by the educator to improve the student’s opportunity to learn. All students, including those with auditory processing deficits (APDs), require an optimum listening environment. Classroom management suggestions identified for a student with an APD should be based on the student’s individual profile of auditory processing strengths and weaknesses. The audiologist should select those strategies most appropriate for the student’s needs.

UNIVERSAL LEVEL STRATEGY

BENEFIT

Teach and cue students to “look and listen”

■■

Check students’ comprehension of verbal information by asking open-ended questions

■■ ■■ ■■

S = state the topic to be discussed P = pace your conversation at a moderate speed with occasional pauses to permit comprehension E = enunciate clearly, without exaggerated lip movements E = enthusiastically communicate, using body language and natural gestures CH = check comprehension before changing topics Provide multisensory instruction

■■

■■

■■

Improves students’ comprehension by watching person who is speaking Determines students’ level of understanding information Identifies information that needs to be restated Verifies when students are ready to move into new material Provides a mnemonic device for highlighting basic strategies dealing with attending, memory, and receptive language deficits

Chapter 6

Increases instructional access through the use of multiple learning modalities Allows sustained reference to instruction when visual supplements are utilized

TARGETED LEVEL (includes all of the above plus those below) STRATEGY Seat student near teacher or speaker with full face to face view

BENEFIT ■■ ■■ ■■ ■■

Decrease distance and obtain eye contact while redirecting Obtain student’s attention through visual, auditory, or tactile cues as appropriate

Provides louder, less reverberant signal Provides advantage of visual instruction aids Provides access to visual spoken language Helps maintain attention and interest to task

■■

Improves audibility Gains auditory attention

■■

Prepares student for listening

■■

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STRATEGY

217

BENEFIT

Provide earmuffs or quiet study areas that are free from visual distractions during independent work time Monitor student for fatigue and length of attending time, providing breaks when necessary Assign peer note-taker

■■

Helps to minimize problems with auditory and visual distractions in the environment to improve concentration and productivity

■■

Permits student to have “downtime” and then redirects attention

■■

Permits student to have access to additional student notes

INTENSIVE/INDIVUALIZED LEVEL (includes all of the above plus those below) STRATEGY Use classroom or personal FM under direction of the educational audiologist Make available computer-assisted note-taking

BENEFIT ■■

Allows for direct access to teacher’s voice

■■

Provides student with notes of lectures

Chapter 6

Note. Revised from Colorado Department of Education, Exceptional Student Leadership Unit, (Central) auditory processing deficits: A team approach to screening, assessment & intervention practices, 2008. Reprinted with permission. http://www .cde.state.co.us/cdesped/rs-edaudiology

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APPENDIX

6–J

A Multitiered Model of Auditory Processing Deficit Interventions

Chapter 6 218

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CHAPTER

7

Classroom Acoustics and Other Learning Environment Considerations CONTENTS

Chapter 7

Learning Environments and At-Risk Students Listening and Learning Challenges ■ Lighting and Learning Challenges ■ At-Risk Students Universal Design for Learning Properties of Classroom Acoustics Noise ■ Signal-to-Noise Ratio ■ Reverberation ■ Inverse Square Law and Critical Distance

High school students’ descriptions of strategies for hearing access in the classroom.

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CONTENTS 

(Continued )

Classroom Acoustics and Speech Perception Effects of Noise on Speech Perception ■ Effects of Reverberation on Speech Perception Combined Effects of Noise and Reverberation on Speech Perception ■ Effects of Classroom Acoustics on Teachers Classroom Acoustics Standard History and Development of the Standard ■ Current Standard Status ■ Classroom Audio Distribution Systems ■ Conformance and Tolerance Verification ■ Standard Adoption Classroom Acoustics Resolutions and Guidelines Measuring Classroom Acoustics Classroom Observation ■ Instrumentation and Software Programs ■ Classroom Noise Measurements ■ Classroom Reverberation Measurements ■ Estimating Critical Distance Role of the Educational Audiologist Management of the Learning Environment Summary Suggested Reading and Resources Appendices 7–A Classroom Acoustics Screening Survey Worksheet (Text/Online) 7–B Using the Student, Environments, Tasks, and Tools Framework to Identify Assistive Technology and Interpreting Services for Students Who Are Deaf or Hard of Hearing (Text/Online) 7–C Resources (Text)

KEY TERMS Classroom acoustics, reverberation, noise, universal design for learning, lighting, SETT framework, noise, signal-tonoise ratio (SNR), reverberation, learning environment, accommodations

KEY POINTS ■■

Chapter 7

■■

■■

■■

■■

When direct sound energy and early reflections are maximized in the learning environment, there should be no interference with speech perception and learning. Light matters; research shows that students perform better in classrooms with daylight. The principles of Universal Design for Learning (UDL) should guide learning for all students. The SETT framework is a key tool for analyzing student needs for hearing assistance technology and other accommodations. Critical distance is determined based on room size and the reverberation time. Listeners who are seated beyond the critical distance in the learning environment may experience difficulty listening, and as a result, learning opportunities may be missed.

The classroom environment is a gatekeeper to learning. Even when the best teacher delivers the best instruction, the student’s ability to access that instruction is limited when the classroom environment is poorly constructed. Good classroom environments benefit all students and their teachers. Learning environments should be free from excessive noise and reverberation and have appropriate lighting and space to achieve effective communication and positive educational outcomes. Students should be educated in facilities that allow them to focus their efforts on thinking and learning rather than struggling to listen and see. National attention has been focused on these concerns, and standards and guidelines have been developed to provide the necessary acoustic qualities in classrooms to allow for effective communication between students and teachers (American Academy of Audiology [AAA], 2008; American SpeechLanguage Hearing Association [ASHA], 2005b; 2005c; ANSI/ASA, 2010; U.S. Green Building Council, 2009). In addition to physical barriers to learning, Universal Design for Learning (UDL) promotes accessibility to instruction and the curriculum to engage all learners through multiple modalities of instruction and recognizing multiple ways of expression. UDL’s strengths-based approach accommodates learners with a variety of strengths and needs. Today’s classrooms utilize instructional trends, methodologies, and

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■■ ■■ ■■ ■■

■■

■■ ■■

■■

Why is the acoustic environment important to learning? Why is the visual environment important to learning? What are the parameters of classroom acoustics? What are the parameters of visual access in the classroom? What standards dictate/guide classroom acoustic environments? How are classroom acoustic properties measured? What is the educational audiologist’s role in evaluating, monitoring, and modifying classroom acoustic and visual environments? Who should the educational audiologist collaborate with to promote appropriate classroom acoustics and visual access?

Speaking and listening are the primary communication modes in auditory learning environments, where children are involved in listening activities for 60% to 75% of their school day (Butler, 1975; Dahlquist, 1998). Teachers, administrators, architects, engineers, audiologists, parents, and a host of other professionals are concerned about classroom acoustics. The U.S. General Accounting Office (1995) report addressed classroom acoustics, among other environmental factors, and estimated that approximately 22,000 U.S. schools attended by 11 million students had unsatisfactory acoustics for noise control. The survey revealed that teachers in 28% of schools reported unsatisfactory acoustic environments. A decade later, the U.S. Department of Education (2005) surveyed school principals on similar environmental factors. The survey was mailed to 1,205 of 84,000 principals of elementary and secondary schools and yielded a 90% return rate. Principals rated acoustics and noise control as very satisfactory or satisfactory for classrooms in 86% of permanent buildings (86%) and 77% of portable or temporary classrooms. Principals estimated that acoustics or noise control would be more likely to interfere with instruction in portable buildings (18%) than in permanent buildings (12%). Differences in the outcomes of these two studies may be the result of the perceptions and experiences of the two groups of respondents.

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Historically, acoustic considerations in the design of schools have been described as the “forgotten variables” to ensuring students’ academic success, particularly students with unique communication or educational needs (Crum & Matkin, 1976). Poor classroom acoustics and lighting can compromise academic, communicative, psychosocial, and psychoeducational performance in children and place teachers at risk for developing vocal problems. Focus on acoustic performance requirements has emerged as a national agenda item in educational facility planning and design. New approaches to curriculum development and facility design have redirected emphasis from the more traditional teaching places concept to the learning spaces concept. Many school districts are subscribing to the minimal acoustic and lighting performance requirements that are part of the indoor environmental quality (IEQ) guidelines for new construction and major renovation projects to achieve a level of LEED (Leadership in Energy and Environmental Design) certification (U.S. Green Building Council). Based on the IEQ guidelines, the following strategies for improving comfort and control are recommended (https://www.usgbc.org/articles /green-building-101-what-indoor-environmental-quality): ■■ ■■ ■■ ■■ ■■ ■■ ■■

use daylighting; install operable windows; give occupants temperature and ventilation control; give occupants lighting control; conduct occupant surveys; provide ergonomic furniture; and include appropriate acoustic design.

The educational audiologist can assist school districts and facility planning groups to improve acoustic conditions in listening and learning environments as well as advocate for appropriate lighting and visual access. Although many resources are available, the educational audiologist possesses the knowledge and skills to provide information about the benefits of good classroom acoustics, evaluate educational acoustic environments, and advocate for endorsement of the classroom acoustics standard and related guidelines and requirements.

LEARNING ENVIRONMENTS AND AT-RISK STUDENTS

Chapter 7

technologies that have produced changes in both teaching and learning. Digital Immigrant teachers (i.e., late adopters of digital technology) have been challenged to creatively meet the demands of their Digital Native students for whom digital technologies already existed when they were born and who have grown up with access to digital technology (Prensky, 2001). Implementation of innovative, specialized, and interactive teaching and learning strategies designed to enhance the learning process can produce additional classroom noise that contributes to the acoustic complexity of many learning environments. Differentiated instruction, cooperative learning, center-based learning, and a wealth of interactive technological advancements contribute to the acoustic and lighting signature of the learning environment and instruction. This chapter addresses the following questions:

221

Listening and Learning Challenges High levels of classroom noise have been shown to negatively affect reading comprehension, auditory and visual attention, short-term memory, behavior, and social skills in all children (Ferguson, Cassells, MacAllister, & Evans, 2013; Howard, Munro, & Plack, 2003). Specifically, noise, reverberation, distance, and directionality are elements in the classroom that can affect a listener’s speech perception abilities (see Figure 7–1). Students, particularly those in

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222

Chapter 7

FIGURE 7–1  Noise, reverberation, distance, and directionality interact in a synergistic manner and can interfere with speech perception in learning spaces.

Chapter 7

the early grades, are more vulnerable to the effects of poor classroom acoustics requiring a quieter environment and signal clarity in order to hear, listen, and comprehend (Berg, Blair, & Benson, 1996; Crandell, 1993; Nelson, 2003; Papso & Blood, 1989; Yacullo & Hawkins, 1987). The youngest students, whose classrooms are very often the noisiest due to activity levels, are the most vulnerable to the effects of noise (Jamieson, Kranjc, Yu, & Hodgetts, 2004; Picard & Bradley, 2001). There are differences between the acoustic requirements for children and adults regarding the effects of noise and reverberation on speech perception. Adults are more mature and skillful listeners who rely on their language and life experiences to assist with auditory closure and gaining meaning in less than optimal acoustic conditions. Conversely, children are more adversely affected by noise and reverberation as the central auditory pathways, specifically interhemispheric organization and neural synchrony, do not reach maturity until adolescence (Anderson, 2004; Bellis, 2005; Elliott, 1979; Soli & Sullivan, 1997). Children, whose auditory systems are still developing, are constantly challenged to resolve the competition for speech perception and localization between a sound source and noise or reverberation (Litovsky, 2002). As a result, they perform more poorly than adults during complex listening tasks such as trying to understand speech in noisy or reverberant rooms.

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Nelson (2003) presented five theories that support these differences: (a) inefficient, broadband listening strategy; (b) inefficient auditory closure; (c) immature weighting of acoustic information; (d) increased susceptibility to distracters; and (e) immature ability to segregate concurrent signals from noise. These theories are not independent. For instance, as students become more sophisticated listeners, they learn weighting strategies to help them attend to acoustic properties that provide contextual information to assist with auditory closure. They also are more distracted by noise than are adults, even if the noise is irrelevant. There are five acoustic factors most likely to affect speech perception in a dynamic classroom: (a) background noise, (b) signal-to-noise ratio (SNR), (c) reverberation time, (d) speaker-listener distance and directionality, and (e) interaction among these variables. The interaction among these elements can affect the degree to which information-carrying components of the speech signal are preserved (Crandell & Smaldino, 2000b; Palmer, 1997; Smaldino, Crandell, Kreis­ man, John, & Kreisman, 2009). Variables that affect the listening process in the classroom include acoustic signals, potential barriers in the listening environment, and listener constraints (Bellis, 2005; Crandell & Smaldino, 2000b; Nelson & Soli, 2000). In addition to the teacher and student, the intensity level and clarity of other instructional audio sources (e.g., LCD projector, computers, streaming media,

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Classroom Acoustics and Other Learning Environment Considerations

video, podcasting) must be considered. Additional factors that can influence speech recognition include linguistic elements (e.g., word and vocabulary familiarity, context, number of syllables in words, linguistic competency of the listener), articulatory factors (e.g., speaker gender, dialect, articulatory abilities of the speaker), and auditory attention and memory (e.g., classroom disruptions that interfere with access to instruction). The listening process in the classroom is affected by acoustic and nonacoustic variables and a variety of listener constraints that are summarized in Figure 7–2.

Lighting and Learning Challenges

rooms with more daylight had higher average achievement test scores after taking into account the free or reduced-price lunch variable and other aspects of the school facility design (Tanner, 2008). Similarly, a study of 102 schools in California, Colorado, and Washington found, and confirmed in a follow-up study, that students in the classrooms with the most daylight increased their test scores overall about 21% more than those students in rooms with the least amount of daylight after taking into account additional information, including teacher characteristics and grade levels (Heschong, Elzeyadi, & Knecht, 2002). What about when daylight is limited or not available? Hathaway (1995) reported that average student test scores in classrooms with full-spectrum bulbs increased their level of academic achievement by about two grade levels over the

Chapter 7

Lighting also impacts learning. A study of 24 elementary schools in Georgia found that third-grade students in class-

223

FIGURE 7–2  Variables that affect the listening process in the classroom include the acoustic signals, potential barriers in the listening environment, and listener constraints (Bellis, 2005; Crandell & Smaldino, 2000a; Nelson & Soli, 2000).

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224

Chapter 7

2-year study period, compared with 1.6 years for students in classrooms with high-pressure sodium vapor bulbs.

TABLE 7–1  At-Risk Populations for Learning in Poor Acoustical Environments ■■ ■■

At-Risk Students

■■

Some students are at greater risk for missed learning opportunities in the presence of excessive noise and reverberation. Crandell, Smaldino, and Flexer (2005) provided a comprehensive overview of specific populations of students with normal hearing and reduced hearing who are at-risk learners in poor acoustic conditions (see Table 7–1). Four basic concepts associated with classroom acoustics describe these listening, learning, and educational design challenges (ASHA, 2005; Smaldino & Flexer, 2012;).

■■

1. In every classroom there are students who have either permanent or fluctuant hearing loss or difficulty processing speech and language, and the incidence is more prevalent with younger children. 2. Listening and learning are affected when students cannot hear clearly, and subsequently, skills involved in auditory processing and learning to read are impacted. 3. Listening and learning problems can be intensified due to excessive noise and reverberation and the loss of intensity of the teacher’s voice over distance or change in directionality. 4. Improving classroom acoustics may require attention to architectural design principles and elements, and/or acoustic modifications, and in some situations, the use of hearing assistive technologies.

■■

Chapter 7

The prevalence of minimally reduced hearing in children is between 4.5% (Bess, Dodd-Murphy, & Parker, 1998) and 12.5% (Niskar et al., 1998). Students with minimalto-mild hearing levels, when compared to normal hearing peers, exhibit differences on speech perception tasks in the presence of competing noise that include (a) overall poorer performance on speech perception tasks, (b) missing more high-frequency consonant information, and (c) a greater degree of degradation in performance as a function of less favorable speech-to-competition ratios. In addition, these students exhibit characteristics that include a higher degree of psychosocial or physical health problems in the areas of energy, behavior, stress, self-esteem, and social support, and lower performance on achievement tests. Among other students with hearing or auditory deficits who have been found to experience decreased speech perception in noise are those with auditory neuropathy dyssynchrony, cochlear implants, unilateral hearing loss, and recurrent otitis media (Crandell, 1991, 1992, 1993; Crandell & Bess, 1986; Fetterman & Domico, 2002; Finitzo-Heiber & Tillman, 1978; Johnson, Stein, Broadway & Markwalter, 1997; Johnson, 2000; Poissant, Whitmal & Freyman, 2006; Zeng & Fui, 2006). Other at-risk learners in less than optimal acoustic conditions include students with learning disabilities, devel-

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■■ ■■ ■■ ■■ ■■ ■■ ■■ ■■

Young children (20,000 ft3 (566 m3)

40/60

n/a

40/60

35/55

n/a

Enclosed volumes 20,000–40,000 ft3 (560–1120 m3)

40/60

1.0

Enclosed volumes 40,000–80,000 ft3 (1120–2240 m3)

40/60

1.2

Enclosed volumes 80,000–160,000 ft3 (2240–4480 m3)

40/60

1.4

Enclosed volumes 160,000–320,000 ft3 (4480–8960 m3)

40/60

1.6

Enclosed volumes 320,000–640,000 ft3 (8960–17,920 m3)

40/60

1.8

Enclosed volumes >640,000 ft3 (>17,920 m3)

40/60

2.0

All ancillary learning spaces

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40/60

40 dBA

40/60

35/55

40 dBA

No requirement

No requirement

n/a

No requirement

Chapter 7

Core Learning Space

NA

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234

Chapter 7

FIGURE 7–4  International Code Council (ICC) standards.

The requirements set specific criteria for maximum classroom size considered, maximum reverberation time, and background noise in classrooms. Within this same section, the ICC also instituted standards for sign language interpreter stations (area to stand, viewing angle for audience, illumination, backdrop).

Local and State Adoption

Chapter 7

School districts may specify compliance with the standard as part of the construction design for new schools, thus making the design team responsible for addressing classroom acoustics. Parents may find the standard useful as a guide to classroom accommodations under the IDEA (Individuals with Disabilities Education Act). Among the early adopters of ANSI/ASA (2010) were the New Hampshire Department of Education, New Jersey School Construction Board and State Board of Education, State of Connecticut, State of Minnesota, Maryland Department of Education, the Ohio School Facility Commission, New York City Public Schools, and Arlington County (VA) Public Schools. These proactive entities effectively assigned the responsibility for good classroom acoustics to school design teams. Internationally, classroom acoustic standards have been established in the United Kingdom, Australia, New Zealand, Sweden, the Netherlands, Italy, Switzerland, Denmark, Finland, Germany, and the World Health Organization.

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The number of states, local jurisdictions, and boards of education that have taken action on classroom acoustics continues to grow. Several states, such as Maryland (2006) and New Jersey (2007), developed web-accessible classroom acoustics guidelines and design manuals that include acoustic comfort guidelines, implementation specifications for renovations and learning spaces such as portable classrooms, and suggestions for managing classroom acoustics in new and existing classrooms. School districts generally cite lack of funding as the primary opposition to implementing the classroom acoustics standard. Addressing acoustics as part of the design or renovation process is more cost effective than retrofitting existing learning spaces. According to the Access Board (2003a), only 10% of a school district’s budget is consumed by facility design and construction costs. Addressing classroom acoustics in the design phase increases overall construction costs by only 1% to 3% (Nelson, 2003), with retrofit costs being as much as 30% higher to achieve improved classroom acoustics. The Access Board’s publication, Counting the costs of noisy vs. quiet classrooms (2003a), provides a thoughtful discussion of construction cost analysis and design criteria and elements needed to produce a good acoustic environment for learning. The educational audiologist will find many resources later in this chapter to assist in presenting to school planning groups on the rationale for dealing with classroom acoustics in the design phase (as opposed to acoustic modification costs) and the effects that poor acoustic environments have on student learning and teacher’s vocal health.

CLASSROOM ACOUSTICS RESOLUTIONS  AND GUIDELINES The American Academy of Audiology (AAA) and the Amer­ ican Speech-Language-Hearing Association (ASHA) convened task forces to specifically develop position statements on classroom acoustics. ASHA approved a position statement and accompanying technical report and guidelines on acoustics in educational settings that endorse the ANSI standard in 2005. This document includes information on the roles of the audiologist as well as the acoustic consultant while clearly delineating when it is more appropriate for the acoustic consultant to take the lead role. For instance, while both can recommend modifications, the acoustic consultant is better trained to select the materials. The AAA passed a resolution in 2008 in full support of the ANSI standard. This position statement also supports national awareness and implementation of the standard and various efforts to promote awareness of the standard as well as research on the effects of classroom acoustics on educational outcomes for all learners. Classroom acoustics is a national agenda item for the U.S. Green Building Council (2009) as part of the LEED

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Classroom Acoustics and Other Learning Environment Considerations

MEASURING CLASSROOM ACOUSTICS The 21st-century dynamic classrooms are active learning environments where the acoustic parameters change as a function of time, the specific learning activity, and other factors (Smaldino, Crandell, & Kreisman, 2005). Prior to measuring classroom acoustics (i.e., noise and reverberation), the educational audiologist should conduct an observation of the specific learning space(s). The following overview of classroom acoustics measurements can be supplemented with resources found in Appendix 7–C and selected references that provide specific protocols for measuring classroom acoustics. The ANSI/ASA standard (2010) and the AAA Clinical Practice Guidelines for Remote Microphone Hearing Assistance Technologies for Children and Youth Birth to Age 21 Years (2008)–Supplement B, Classroom Audio Distribution Systems identify specific procedures to be used in measuring classroom acoustics that include (a) measuring background noise levels in dBA, (b) measuring or estimating reverberation time, and (c) measuring or estimating the SNR. In addition, the estimation of critical distance should be included as part of the classroom survey and acoustic measurements. The Classroom Acoustics Screening Survey Worksheet located in Appendix 7–A is an excellent tool for the educational audiologist to use for data collection. This comprehensive worksheet includes four essential components

Plural_Johnson_Ch07.indd 235

for documenting the acoustic parameters in classrooms and detailed directions for measuring classroom noise and reverberation levels and estimating critical distance. The observation section provides for a subjective appraisal of noise and reverberation characteristics and information about teaching style and physical room characteristics. Charts are available for recording noise (ambient noise, teacher voice levels) and reverberation measurements (room volume and RT) and for estimating critical distance by utilizing the Critical Distance Chart. The survey form also includes sound absorption coefficients for common classroom facility materials (i.e., floor, walls, ceilings). In the following discussion of classroom acoustic measurements, refer to this document for specific measurement procedures designed for the needs of the educational audiologist.

Classroom Observation Conduct a classroom observation when concerns are expressed regarding acoustic conditions in classrooms. Whenever possible, observe under both the occupied and unoccupied conditions, prior to measuring noise and reverberation. Referrals for consultation about classroom acoustics generally emerge as (a) general concern about noise and reverberation levels; (b) student-specific concern related to hearing status, auditory processing, or the effects of noise and reverberation on academic achievement; or (c) concern expressed by a teacher experiencing excessive vocal stress or fatigue. Observational data are useful in making follow-up recommendations for acoustic modifications in the teaching and learning environment. Classroom observation forms designed for this purpose include space to note the footprint of the classroom and information collected when surveying the classroom. Observation forms also include information gathering for details such as classroom configuration including arrangement of furniture; wall, ceiling, and floor surfaces; noise sources (e.g., external, internal, HVAC, instructional equipment); teaching style; special student needs; and the recording of noise and reverberation measurements. Interviewing the teacher provides the educational audiologist with information about general classroom acoustics concerns and those specific to student learning and the teacher’s vocal health. At times it may also be necessary to observe a specific student who has been referred due to concerns about a possible listening problem. The Classroom Acoustics Screening Survey Worksheet includes an observation section as previously described.

Chapter 7

rating system for new school construction and major renovations. Many school districts are building educational facilities designed to meet the various levels of LEED certification. Under these guidelines for sustainable building, acoustic performance is included in the Indoor Environmental Quality (IEQ) section. The intent of the acoustic performance prerequisite is consistent with the ANSI/ASA S12.60 (2010) standards for classrooms and core learning spaces. The LEED IEQ standard for Minimum Acoustical Performance standard includes requirements for HVAC systems and options for acoustic treatment compliance. Educational facilities that meet the requirement earn credit toward the LEED certification and additional credit if the facility meets the Enhanced Acoustical Performance criteria for effective acoustic design. Specific requirements for Minimum Acoustical Performance address small (2 yrs below grade level Personal Hearing Instrument:  Hearing Aid(s)  Cochlear Implant(s)  Bone anchored device  None/other___ Hearing Assistance Technology used:  Personal FM System  Classroom Audio Distribution System  None  Other Educational Interpreter assigned?  Yes  No

Meets state’s minimum standard?  Yes  No

IEP Related and Support Services: Area Speech-language therapy English Language Learner (ELL) Educational audiology Occupational therapy/physical therapy Psychology/mental health Counseling (by psychologist or social worker) Behavior/Positive Behavior Intervention/Support Plan Other support services:  Parent counseling and training  Transportation

Has had training with D/HH? If provided, is service… Yes □ No □ Yes □ No In class: □ Out of class □ Yes □ No □ Yes □ No In class: □ Out of class □ Yes □ No □ Yes □ No Yes □ No □ Yes □ No Yes □ No □ Yes □ No Yes □ No □ Yes □ No Yes □ No □ Yes □ No  Deaf/Hard of Hearing Role Models  Parent Support Groups/Activities  After school programs

□ □ □ □ □ □ □

©PARC: 2B-Elementary Placement Checklist. C. D. Johnson, M. Darr, S. Elliott. Revised 2011.

1

NOTE: If an item is not relevant for a child, please write “NA” in the “NO” column. I. Classroom- Physical Environment YES 1.

2. 3. 4. 5. 6.

Is the room size conducive to learning? (A large room/high ceiling can distort sound; a small room may be noisier.) Is the room adequately lit? (Lighting and shadows may affect speechreading and signing abilities.) Is the ambient noise level for the classroom within recommended standards (noise ≤35dbA and reverberation ≤.6 sec, ANSI S12.60-2009/10)? Is the room treated to reduce noise (carpet on floor, acoustical ceiling tiles, window coverings, cork or other wall coverings)? Are noise and movement sources in the classroom minimized (e.g., computers, ventilation/heater fans, fish tanks, small group activities)? Does noise from adjacent spaces (hallways, outside the building) spill over into classroom?

NO

____

____

____

____

____

____

____

____

____

____

____

____

Comments____________________________________________________________________________

II. General Learning Environment 7. 8. 9. 10. 11. 12. 13.

Do teacher(s)/adult(s) use a variety of techniques to elicit positive behavior from students? Are there a variety of centers (fine motor, art, manipulatives, science, music, dramatic play, sensory, literacy) or opportunities for demonstrating learning? Is there a visual schedule identifying daily routines and student expectations? Is there a visual behavior management system that provides clear structure for the class and consistent rules? Is the curriculum standards-based including a variety of themes, topics, and children’s literature? Does the teacher use lesson plans to guide daily activities? Are activities modified to meet a variety of students’ needs?

YES

NO

____

____

____ ____

____ ____

____

____

____ ____ ____

____ ____ ____

Comments____________________________________________________________________________

III. Instructional Style 14. Classroom Discourse and Language a. Are the teacher(s), students, and other adults good language models for the student? b. Is language consistently accessible to this student? If sign/cueing is used, does the interpreter/transliterator, or all adults in the classroom if no interpreter, consistently sign/cue, including communications with other adults? c. Are peer responses repeated or signed/cued? d. Is vocabulary and language expanded by the teacher? 15. Teacher’s Speaking Skills a. Is enunciation clear? b. Is rate appropriate? c. Is loudness appropriate? d. Is facial expression used to clarify the message? e. Are gestures used appropriately? f. Are teacher’s (or other speaker’s) lips available for speechreading? g. Is teacher’s style animated? h. Is a buddy system available to provide additional assistance or clarification? 16. Use of Visual Information a. Are props or other visual materials used for stories and activities? b. Are appropriate attention-getting strategies utilized? c. Are overhead projectors, VCRs, LCDs, Smart Boards and other equipment to provide visual supplements utilized? d. Is computer assisted notetaking, or a comparable procedure, utilized to support ©PARC: 2B-Elementary Placement Checklist. C. D. Johnson, M. Darr, S. Elliott. Revised 2011.

YES

NO

____

____

____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____

____ ____

____ ____

____

____

2

access to course content, instruction, and discourse amongst the class? Is visual information accessible to the student (e.g., within view, written in appropriate language)? Oral Discussion/Small Groups a. Are all students encouraged to share and participate? b. Does the teacher face the students when speaking? c. Do the students face one another when speaking? d. Does the teacher lead group activities in an organized and student-friendly manner? e. Is appropriate wait time utilized to encourage students to think and participate? f. Are students seated within the teacher’s “arc of arms”? g. Does the teacher obtain eye contact prior to and while speaking? h. If used, is the FM microphone passed around to all speakers? Use of Sign/Cued Speech a. If an educational interpreter/transliterator is assigned to the student, does the interpreter/transliterator promote student self-advocacy yet assure full access to all communication in the classroom? b. Is the interpreter/transliterator familiar with the student’s IEP, and does s/he know his/her role in its implementation? c. Does the interpreter/transliterator adjust the language in order to make it more accessible to the student? d. Does the interpreter/transiliterator make changes to content vocabulary for the student? e. Does the interpreter/transliterator expand on concepts presented in class? f. Is sign/cued speech consistently used by all adults in the class? g. Are teachers and paras proficient in the sign/cued mode of the student? h. Is sign/cuing consistently used by all students in the class? i. Does the type of sign/cuing used in the classroom match the signs/cues used by this student? j. Is fingerspelling used? k. Are there opportunities for parents and peers to learn to sign/cued speech? l. Do they take advantage of them? Opportunities for Hands-on Experience a. Are a variety of materials available? Check those used:  books  visual props  audio/video CDs/DVDs  objects for dramatic play  manipulatives b. Are stories experienced in a variety of ways? c. Are there field trips? d. Are art and sensory activities conducted? Amplification/Technology a. Are personal hearing instruments (hearing aids/cochlear implants) and hearing assistance devices (FM, infrared) checked at school each day? b. Is amplification used consistently in all learning environments? c. Are current instructional technologies used (Smart boards, computers, internet)? e.

17.

18.

19.

20.

____

____

____

____

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____  Not Applicable ____

____

____

____

____

____

____ ____ ____ ____ ____

____ ____ ____ ____ ____

____ ____ ____ ____

____ ____ ____ ____

____

____

____ ____ ____ ____ ____ ____  Not Applicable ____ ____ ____ ____ ____ ____

Comments____________________________________________________________________________

IV. School Culture 21. 22. 23. 24. 25. 26.

Is there evidence that the school administration supports students with disabilities? Is the school welcoming of parents and does it encourage parent involvement? Is the school/district administrator knowledgeable about hearing loss or willing to learn? Is the school committed to making the necessary accommodations for students with hearing loss? Is the teacher open to consultation with other professionals or specialists? Does the teacher provide opportunities for individualized attention?

©PARC: 2B-Elementary Placement Checklist. C. D. Johnson, M. Darr, S. Elliott. Revised 2011.

YES

NO

____ ____

____ ____

____

____

____ ____ ____

____ ____ ____ 3

27. 28. 29.

Is the teacher welcoming of students with special needs? Is the teacher willing to use and troubleshoot hearing assistance technology (e.g., FMs) and other technologies (e.g., captioning, transcription)? Are the extra-curricular (sports, drama, clubs) staff and settings prepared to assure communication access for this student?

____

____

____

____

____

____

Comments____________________________________________________________________________

V.

Reflection: Individual Student Considerations

30. Communication and Language Think about how this student communicates thoughts, ideas, and needs. Think about how this student interacts with other students. Will his/her communication be nurtured in this classroom environment? Are there opportunities for direct communication with peers and professionals in the student’s language and communication mode and at the student’s academic level? Is there direct instruction in the student’s language and communication mode? Does this student have sufficient language abilities to benefit from instruction in the classroom (generally within 2 years of most students in the class)? Will this student develop English language competency in this environment? 31. Social Interactions, Self-Concept, Self-Efficacy, and Self-Advocacy Think about how this student plays and behaves alone and in groups. Think about how this student interacts with other students. Will this student’s social skills and selfconcept be nurtured in this classroom environment? Will this student be supported to develop self-efficacy and self-advocacy skills? 32. Listening Skills Does this student attend well? Is this student able to listen and process information in noise? Think about what this student does when he/she cannot hear? Does this student take responsibility for his/her personal hearing instruments? Will this student’s listening needs be supported in this classroom, lunchroom and all other school environments? Is the staff qualified and able to support the student’s listening needs?

YES

NO

____

____

____

____

____ ____  Not Applicable

Comments____________________________________________________________________________ ___________________________________________________________________________________

©PARC: 2B-Elementary Placement Checklist. C. D. Johnson, M. Darr, S. Elliott. Revised 2011.

4

PARC: Placement And Readiness Checklists Part 2C: Placement Checklist for Students who are Deaf and Hard of Hearing: SECONDARY Before the Individual Education Program (IEP) team makes a decision regarding services and placement for a student who is deaf or hard of hearing, two areas should be considered. First, is the student ready for the placement under consideration and, second, is the classroom environment under consideration sufficiently prepared to support the student? This checklist is the Placement component of this two part instrument. Its purpose is to guide considerations and decisions related to placement and service options for students who are deaf or hard of hearing in middle school and high school. Ratings may also guide the IEP team in providing supports when needed. The companion set of checklists consider the readiness of the student for the various learning environments and situations under consideration. The information to complete this placement checklist should be obtained through observation and discussion with the current teacher, the prospective teacher(s), the parents and other members of the IEP team. Placement decisions should consider the student’s communication, language, academic, and social needs in the context of the proposed learning environment. Note: Each area or item may not be applicable to every student. Student: ____________________________________________

Date: _________________________

Person completing this form: ______________________________

Title: _________________________

Name of School: _______________________________________

Grade: ________________________

Type of Classroom:

 Special education class  General education class  At-risk class  Deaf education class  Co-taught class  Other_________________ If primary instructor is not a deaf education teacher/specialist, describe any previous experience with students who are deaf or hard of hearing:_______________________________________________________________ IEP Deaf education services:

 Consultation/Itinerant  Direct- in classroom  Direct- out of classroom  Special School  other____________________________________

Range of class size of student’s in classrooms: ___to___

Number of students with hearing loss in school: ______

Student’s communication mode(s): _________________

Mode(s) observed in classroom: __________________

Receptive language level:  above grade level  at grade level  1-2 yrs below grade level  >2 yrs below grade level Expressive language level:  above grade level  at grade level  1-2 yrs below grade level  >2 yrs below grade level Personal Hearing Instrument:  Hearing Aid(s)  Cochlear Implant(s)  Bone anchored device  None/other___ Hearing Assistance Technology used:  Personal FM system  Classroom Audio Distribution System  None  Other____________________________________________________ Educational Interpreter assigned?  Yes  No

Meets state’s minimum standard?  Yes  No

IEP Related and Support Services: Area Speech-language therapy English Language Learner (ELL) Educational audiology Occupational therapy/physical therapy Psychology/mental health Counseling (by psychologist or social worker) Behavior/Positive Behavior Intervention/Support Plan Other support services:  Parent counseling and training  Transportation

□ □ □ □ □ □ □

Has had training If provided, is service… with D/HH? Yes □ No □ Yes □ No In class: □ Out of class □ Yes □ No □ Yes □ No In class: □ Out of class □ Yes □ No □ Yes □ No Yes □ No □ Yes □ No Yes □ No □ Yes □ No Yes □ No □ Yes □ No Yes □ No □ Yes □ No  Deaf/Hard of Hearing Role Models  Parent Support Groups/Activities  After school programs

©PARC: 2C-Secondary Placement Checklist. C.D. Johnson, M. Darr, S. Elliott. Revised 2011.

1

NOTE: If an item is not relevant for a child, please write “NA” in the “NO” column. I. Classroom- Physical Environment YES 1.

2. 3. 4. 5. 6.

Is the room size conducive to learning? (A large room/high ceiling can distort sound; a small room may be noisier.) Is the room adequately lit? (Lighting and shadows may affect speechreading and signing abilities.) Is the ambient noise level for the classroom within recommended standards (noise ≤35dbA and reverberation ≤.6 sec, ANSI S12.60-2009/10)? Is the room treated to reduce noise (carpet on floor, acoustical ceiling tiles, window coverings, cork or other wall coverings)? Are noise and movement sources in the classroom minimized (e.g., computers, ventilation/heater fans, fish tanks, small group activities)? Does noise from adjacent spaces (hallways, outside the building) spill over into classroom?

NO

____

____

____

____

____

____

____

____

____

____

____

____

Comments____________________________________________________________________________ ___________________________________________________________________________________

II. General Learning Environment 7.

YES

Do teacher(s)/adult(s) use a variety of techniques to elicit positive behavior from students? 8. Is there a visual schedule identifying daily routines and student expectations? 9. Is there a visual behavior management system that provides clear structure for the class and consistent rules? 10. Is the curriculum standards-based including a variety of themes, topics, and age level appropriate literature? 11. Does the teacher use lesson plans to guide daily activities? 12. Are activities modified to meet a variety of students’ needs?

NO ____ ____

____ ____

____

____

____ ____ ____

____ ____ ____

Comments____________________________________________________________________________ ___________________________________________________________________________________

III. Instructional Style 13. Classroom Discourse and Language a. Are the teacher(s), students, and other adults good language models for the student? b. Is language consistently accessible to this student? If sign/cuing is used, does the interpreter/transliterator, or all adults in the classroom if no interpreter/ transliterator, consistently sign/cue, including communications with other adults? c. Are peer responses repeated or signed/cued? d. Is vocabulary and language expanded by the teacher? 14. Teacher’s Speaking Skills a. Is enunciation clear? b. Is rate appropriate? c. Is loudness appropriate? d. Is facial expression used to clarify the message? e. Are gestures used appropriately? f. Are teacher’s (or other speaker’s) lips available for speechreading? g. Is teacher’s style animated? h. Is a buddy system available to provide additional assistance or clarification? 15. Use of Visual Information a. Are props or other visual materials used for stories and activities? b. Are appropriate attention-getting strategies utilized? c. Are overhead projectors, VCRs, LCDs, Smart boards and other equipment to provide visual supplements utilized? d. Is computer assisted notetaking, or a comparable procedure, utilized to support ©PARC: 2C-Secondary Placement Checklist. C.D. Johnson, M. Darr, S. Elliott. Revised 2011.

YES

NO

____

____

____ ____ ____

____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____

____ ____ ____ ____ ____ ____ ____ ____

____ ____

____ ____

____

____

2

16.

17.

18.

19.

20.

access to course content, instruction, and discourse amongst the class? e. Is visual information accessible to the student (e.g., within view)? Oral Discussion/Small Groups a. Are all students encouraged to share and participate? b. Does the teacher face the students when speaking? c. Do the students face one another when speaking? d. Does the teacher lead group activities in an organized and student-friendly manner? e. Is appropriate wait time utilized to encourage students to think and participate? f. Are students seated within the teacher’s “arc of arms”? g. Does the teacher obtain eye contact prior to and while speaking? h. If used, is the FM microphone passed around to all speakers? Use of Sign/Cued Speech a. If an educational interpreter/transliterator is assigned to the student, does the interpreter/transliterator promote student self-advocacy yet assure full access to all communication in the classroom? b. Is the interpreter/transliterator familiar with the student’s IEP, and does s/he know his/her role in its implementation? c. Does the interpreter/transliterator adjust the language in order to make it more accessible to the student? d. Does the interpreter/transiliterator make changes to content vocabulary for the student? e. Does the interpreter/transliterator expand on concepts presented in class? f. Is sign/cued speech consistently used by all adults in the class? g. Are teachers and paras proficient in the sign/cue mode of the student? h. Is sign/cuing consistently used by all students in the class? i. Does the type of sign/cue used in the classroom match the signs/cued speech used by this student? j. Is fingerspelling used? k. Are there opportunities for parents and peers to learn to sign/cued speech? l. Do they take advantage of them? Opportunities for Experiential Learning a. Are a variety of materials available? Check those used:  books  visual props  audio/video Cds/DVDs b. Are stories experienced in a variety of ways? c. Are there field trips? d. Are art and sensory activities conducted? Amplification/Technology a. Are personal hearing instruments (hearing aids/cochlear implants) and hearing assistance devices (FM, infrared) checked at school each day? b. Is amplification used consistently in all learning environments? c. Are current instructional technologies used (Smart boards, computers, internet)? Transition a. Is personal responsibility/self-advocacy development supported for independent thinking and decision-making? b. Is there an emphasis on career exploration and development of career goals? c. Does the student’s education program support his/her post-school goals? d. Are there opportunities for job shadowing within the community? e. When appropriate, are linkages made with adult services (e.g., Voc Rehab)?

____ ____

____ ____

____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____  Not Applicable

____

____

____

____

____

____

____ ____ ____ ____ ____

____ ____ ____ ____ ____

____ ____ ____ ____

____ ____ ____ ____

____

____

____ ____ ____ ____ ____ ____  Not Applicable ____ ____ ____

____ ____ ____

____ ____ ____ ____ ____

____ ____ ____ ____ ____

Comments____________________________________________________________________________ ___________________________________________________________________________________

IV. School Culture 21.

Is there evidence that the school administration supports students with disabilities?

©PARC: 2C-Secondary Placement Checklist. C.D. Johnson, M. Darr, S. Elliott. Revised 2011.

YES ____

NO ____ 3

22. 23. 24. 25. 26. 27. 28.

Is the school/district administrator knowledgeable about hearing loss or willing to learn? Is the school committed to making the necessary accommodations for students with hearing loss? Is the teacher open to consultation with other professionals or specialists? Does the teacher provide opportunities for individualized attention? Is the teacher welcoming of students with special needs? Is the teacher willing to use and troubleshoot hearing assistance technology (FMs) and other technologies (captioning, transcription)? Are the extra-curricular (sports, drama, clubs) staff and settings going to assure communication access for this student?

____

____

____ ____ ____ ____

____ ____ ____ ____

____

____

____

____

Comments____________________________________________________________________________ ___________________________________________________________________________________

V. Reflection: Individual Student Considerations 29. Communication and Language Think about how this student communicates thoughts, ideas, and needs. Think about how this student interacts with other students. Will his/her communication be nurtured in this classroom environment? Are there opportunities for direct communication with peers and professionals in the student’s language and communication mode and at the student’s academic level? Is there direct instruction in the student’s language and communication mode? Does this student have sufficient language abilities to benefit from instruction in the classroom (generally within 2 years of most students in the class)? Will this student develop English language competency in this environment? 30. Social Interactions, Self-Concept, Self-Efficacy, and Self-Advocacy Think about how this student behaves alone and in groups. Think about how this student interacts with other students. Will this student’s social skills and self-concept be nurtured in this classroom environment? Will this student be supported to develop selfefficacy and self-advocacy skills? 31. Listening Skills Does this student attend well? Is this student able to listen and process information in noise? Think about what this student does when he/she cannot hear? Does this student take responsibility for his/her personal hearing instruments? Will this student’s listening needs be supported in this classroom, lunchroom and all other school environments? Is the staff qualified and able to support the student’s listening needs?

YES

____

____

NO

____

____

____ ____  Not Applicable

Comments____________________________________________________________________________ ___________________________________________________________________________________

©PARC: 2C-Secondary Placement Checklist. C.D. Johnson, M. Darr, S. Elliott. Revised 2011.

4

APPENDIX

11–E

Chapter 11 Note. From Hands and Voices (2015), http://www.handsandvoices.org. Used with permission.

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APPENDIX

11–F Sample Section 504 Plan1

Student: _________________________________________________ D.O.B:________ Grade: ____ School: _________________________________________________     Meeting Date:_____________ Qualifying Disability: ______________________________________     Start Date:________________ Case Manager: ___________________________________________    Review Date:______________

The disability impacts the student’s education. [

] YES

[

] NO

Is the student disabled under Section 504?

] YES

[

] NO

[

Chapter 11

Documentation of Disability:

Team Members Present Name

Title

_______________________________________________

________________________________

_______________________________________________

________________________________

_______________________________________________

________________________________

_______________________________________________

________________________________

_______________________________________________

________________________________

Discussion Notes     

1

There is no standard Section 504 plan document.

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Chapter 11

Accommodations/Services Plan Area of Difficulty

Accommodation or Service

Person(s) Responsible

Frequency

Chapter 11 Date Approved: ____________________________________________________ Student Signature: __________________________________________________ I give permission for my son/daughter to receive the above-mentioned services. ____________________________________________________________________________________________ Parent Date

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APPENDIX

11–G

LEGAL INTERPRETATIONS RELATING TO AUDIOLOGY AND DEAF EDUCATION SERVICES1 Case law is determined through the rulings of the court. Cir­ cuit court and state court decisions are regarded in the region or state that the court represents. However, their decisions may serve as the basis for rulings made by the other circuit or state courts. U.S. Supreme Court rulings determine the law of the land. The Office of Civil Rights (OCR) rules on cases that are filed through their office. These rulings also have national implications. The U.S. Department of Educa­tion provides further legal interpretation through the Office of Special Education Programs (OSEP). Clarification and interpretation of federal regulations are made through let­ters of policy clari­ fication written in response to specific in­quiries made by state education officials, parents, or other pertinent parties.

LANDMARK AND IMPORTANT CASE LAW RULINGS Audiology Services Stratham School District v. Beth and David P., 103 LRP 4317 (02-135-JD, 2003 DNH 022) On appeal, courts affirmed an administrative law judge decision ordering the school district to pay for cochlear implant mapping services, and associated transportation expenses, because a proper functioning cochlear implant was necessary for the child to receive FAPE and that service was included under definition of audiology as a related service of IDEA. Avon Local School District 38 IDELR 254 (SEA 2003) Ohio) Impartial Hearing Officer decision orders same. Meagan C. v. ECI Life path Systems (ECI Docket No. 001ECI-0803) (Texas) Cochlear Implant mapping, related audiological testing and associated travel expenses ordered to be paid under Part C and that the IFSP be amended to provide these services (Impartial Hearing Officer) NOTE: Review IDEA 2004 OSEP regulations comments for more clarification in this area. S.P. v. East Whittier City School District, (2018), Ninth Circuit Court of Appeals.

School did not complete a sufficient evaluation of the hearing impairment for the IEP team to reasonably develop a plan designed to provide reasonable education benefit. Although an audiogram was provided by the mother (completed privately), the school district’s assessment only consisted of an auditory skills assessment obtained through observation and review of records. The Court of Appeals ruled that “such a limited review was insufficient to satisfy the District’s evaluation obligation.” (Also see Eligibility below). Detroit City School District – Michigan State Education Agency 15-00085 (2015) Failure to document daily use of FM system as stipulated in student’s IEP was a violation of IDEA regulations. Lack of recording keeping violated 34 CFR 76.731 which requires districts maintain records to show compliance with IDEA.

Chapter 11

Case Law Summary

Auditory Processing Disorders E.M. v. Pajaro Valley Unified School District (2014), Ninth Circuit Court of Appeals Determined that auditory processing disorder constituted an “other health impaired” condition under IDEA; established that the diagnosis must be made by a licensed audiologist as a result of an examination; defined APD according to ASHA’s definition: “a deficiency in neurological processing that adversely affects an individual’s ability to identify and distinguish similar sounds and understand oral communication.” The U.S. Department of Education provided the interpretation of IDEA regulations pertaining to this case.

Ambient Noise Levels Pa. Commw. Ct. 1982. Silvio v. Commonwealth, Depart. Of Educ., 553:577. District did not have to establish exact ambient noise levels for classroom for hearing impaired students because there was sufficient evidence to show that the ambient noise levels were appropriate.

Use of FM System OSEP 1992. Letter to Anonymous, 18 IDELR Parent may request IEP meeting to consider use of FM system if student has current IEP but IEP does not discuss use of such a system. If student does not have current IEP, parent

1

Summarized from the Individuals with Disabilities Education Law Report; compiled and updated by C.D. Johnson 8/2019. The document is intended to provide information; it does not constitute legal advice.

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Chapter 11

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may request an evaluation to determine if a disability is present, and to discuss use of FM system at time of IEP meeting. OCR 1994. Robertson (TN) County School District, 22 IDELR 255. District not in violation of Section 504 or Title II of ADA for failing to properly repair FM listening device since problem was due to static and not faulty repair. SEA AZ 1997. Glendale Union High School District, 26 D IDELR 243 District not required to provide FM trainer to student with speech impairment and normal hearing. OCR 2003 Ceres, CA Unified School District, 39 IDELR 221 Parent of an HI student contended that the child’s classroom teacher did not use an FM device as required by the student’s IEP, which called for the teacher to wear the device 90% of the instructional time as a means of communicating with the student. OCR determined the teacher had experienced intermittent problems maintaining and using the unit. However, evidence confirmed that the school’s principal took steps to identify and correct the problem. The principal, along with a resource specialist instructor, met with the teacher to ensure she understood how to use the device and was aware of the requirements of the child’s IEP.

School’s Role for Providing Hearing Aids OSEP 1993. Letter to Seiler, 20 IDELR 1216 Declares that a hearing aid is considered a covered device under the definition of “assistive technology device”; therefore, if the hearing aid is required by the student with a disability to receive FAPE, and the hearing aid is specified within the student’s IEP as a need, then the district is responsible for providing the hearing aid at no cost to the child or his/her family as per 34 CFR 300.308. OSEP 1994. Letter to Galloway, 22 IDELR 37 Inquiry: Which public agency is responsible for the purchase of a hearing aid if a child’s IEP indicates that the device is necessary—the home school district or a statesupported school for the deaf? Should a state’s regulation, which provides that parents will assume the costs for personal items such as hearing aids, be amended to include the statement “unless otherwise specified in the IEP for educational purposes”? Finding: State determines which public agency must pay for assistive device; state’s regulation regarding financial responsibility for personal items required amendment. OSEP 1995. Letter to Bachus, 22 IDELR 629 LEA must provide eyeglass if they are necessary for FAPE and included in IEP. SEA IA 1999. ALJ determined that FM trainer provided appropriate assistive technology for HI student and that hearing aids were not required to receive FAPE. Parent’s request for reimbursement for hearing aids was denied.

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NOTE: Review IDEA 2004 OSEP regulations comments for more clarification in this area.

Hearing Loss Corrected by a Hearing Aid SEA PA 1995. City of Erie School District, 22 IDELR 394. A student whose hearing loss was corrected by hearing aids, no longer qualified for special education as hearing impaired. The case found that her hearing loss, because corrected, did not interfere with her performance on an IQ test, and the district did not fail to make necessary accommodations for her hearing loss during the assessment process; therefore, the district’s results indicating that she was not gifted were valid.

Public Agency’s Role for Providing Assistive Technology OCR. 1991. Humboldt (AZ) Unified School District, 18 IDELR 28 (Insufficient hearing loss) Lack of evidence to show student’s alleged hearing impairment was substantial enough to qualify as a “handicapped person” under 504. OSEP 1993. Anonymous letter to, 21 IDELR 1126 Inquiry: What obligations does a state have under Part H to provide early intervention services in the form of audiology services and assistive technology (devices and services)? Finding: Part H requires audiology services/assistive technology if necessary, to meet developmental needs of child/family. OSEP 1994. Letter to Gay, 22 IDELR 373. When the IEP indicates the requirement of an assistive technology device, such as a hearing aid, as part of the student’s special education program, then the responsible public agency must provide the device at no cost to the student or his/her family. If a state’s regulations indicate that personal items are to be provided by a student’s parents, an additional statement must be included which explains that personal items specified on the student’s IEP as necessary for FAPE, would be provided at no cost to parents. When the child attends a state-supported school for the deaf, the state’s law, regulation, or policy defines whether the student’s home school or the school for the deaf pays for the device. The responsible public agency may seek funds from other sources provided they ensure FAPE and there is no cost to the student or his/her family. OSEP 1994, Anonymous letter to, 21 IDELR 1057 Inquiry: Is s school district responsible for an assistive technology device, purchased by the parents, if that device is utilized by the student in completion of his/her IEP goals and therefore his/her academic work? Finding: Although not mandatory, assuming liability for family-owned assistive technology devices is reasonable.

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Open Classroom/Minimal Hearing Loss OCR 1994. Brockton (MA) Public Schools, 21 IDELR 1076. Found placement of a student with disabilities, including minimal hearing loss, in an open space resource room was adequate to meet the student’s needs. Placement recommendations were made by a team that included initial acceptance by the student’s guardian. Wachlaorwicz v. School Bd of Indept SD No 832, MN. 42 IDELR 7, (2004) Student with high frequency hearing loss and speech apraxia did not qualify for “hearing disability” according to the state criteria; parents sued the district for not benefit-

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ting from additional supports she did not receive. Issue: the “label” is meaningless . . . you are looking for services to meet the student’s needs.

Communication Method Age v. Bullit County Public Schools, 6th Circuit Court (1982) Placement of profoundly deaf children in a segregated classroom while being instructed in total communication was an appropriate education. Silvio v. Commonwealth of Pennsylvania (1982) Transfer of child with hearing impairment from private oral school to school using total communication would not impede the child’s speaking ability and the association with nonhandicapped children would actually improve her communication with others. Unified School District No. 512, KS (1995) The District’s plan to serve a student who was hearing impaired in a self-contained classroom using total communication was determined appropriate even though the parents wanted placement in an oral program offered at a private school for deaf students.

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OSEP 1994. Robertson TN County School District, 22 IDELR 255 Problem with listening device was static interference, not faulty repair by district. OSEP 1994. Letter to Anonymous, 21 IDELR 745 (Provision of Phonic Ear device) Regarding parent request for use of Phonic Ear hearing device by student with hearing loss placed by parents at parochial school, OSEP indicated that LEA must ensure genuine opportunity for equitable participation in one of public school’s special education programs. However equitable participation does not require district to provide Phonic Ear device as part of its special education and related services. Comment: The audiologist along with the IEP team should determine which type of assistive listening device, if any, is most appropriate to meet the educational needs of the individual student. Parents can provide input into the decision but cannot demand a specific brand or type of equipment. OSEP 1995. Letter to Naon, 22 IDELR 856 Need for assistive technology devices/services must be based upon individual. OSEP 1996. Letter to Anonymous, 24 IDELR 388 Public agency may be responsible for assistive technology devices/services depending upon how addressed in IEP. OSEP 1997. Letter to Culbreath, 25 IDELR 1212 State law governs financial liability for damage or theft of assistive technology devices. OCR 1998. Detroit Public Schools, 29 IDELR 619 Assistive technology at home not required under IEP. OSEP 1998. Letter to Hutcheson, 30 IDELR 708 Both local and state educational agencies have obligation relating to provision of assistive technology devices and services. E.D. PA 1999. East Pennsylvania School District v. Scott B., 29 IDELR 1058 Assistive technology device was inadequate. SEA IA 1999. Ankeny Community School District, 30 IDELR 451 Only assistive technology student required was FM trainer.

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Disability and Eligibility Identification as a Child with Hearing Impairment (FAPE) Phyllene W v. Huntsville City Board of Education (2015), Eleventh Circuit Court of Appeals Child with chronic otitis media, seven surgeries, and fluctuating, progressing to permanent, hearing loss was identified as student with specific learning disabilities throughout school (grades 2–10), consistently performed below grade level in reading and math; mother informed school at each IEP meeting about hearing issues; “preferential seating” provided in 6th grade, fitted with hearing aid in 10th grade. Mother enrolled daughter in private school for 10th grade and filed due process. Independent evaluation by SLP revealed “profoundly impaired language skills,” audiologist revealed long-standing fluctuating hearing levels and severe difficulty understanding speech in background noise. District Court found on behalf of School District because sufficient evidence of school denying FAPE was not provided. Court of Appeals ruled that the district violated IDEA and FAPE by not assessing areas of “suspected” disability (i.e., hearing) despite growing deficiencies without considering the effect they may have on academic progress and that proper evaluation and services may have prevented academic delays. S.P. v. East Whittier City School District (2018), Ninth Circuit Court of Appeals School district did not appropriate evaluate child to provide sufficient information for proper disability category. Therefore, the special factors considerations for children

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identified as deaf or hard of hearing were not applied because the school had identified S.P. as a student with speechlanguage disabilities which resulted in addressing only speech and language delays. (Also see Audiology.)

ADA/IDEA (FAPE)

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K.M. v. Tustin Unified School District, Ninth Circuit Court of Appeals D.H. v. Poway Unified School District, Ninth Circuit Court of Appeals Both are landmark cases in that they establish that students served by IDEA were also eligible under ADA. Decision include U.S. Departments of Education and Justice and provide the 2014 policy guidance, Frequently Asked Questions on Effective Communication for Students with Hearing, Vision, or Speech Disabilities in Public Elementary and Secondary Schools describing eligibility and accommodations. Of most significance is the different standards of the two laws, i.e., ADA requires communication must be “as effective as communication for others,” while IDEA requires schools “to meet each student’s individual needs to provide a “reasonable education program.” Therefore, ADA is a higher standard that can be used to justify services.

Adequate Services and Maximum Potential (FAPE) Hendrick Hudson School District v. Rowley (1982) The first and perhaps most far-reaching ruling regarding the definition of “appropriate” services. The Supreme Court defined “appropriate” as sufficient for educational benefit but not for maximization of the student’s potential. The court further stated that the IEP, and therefore the personalized instruction, should be formulated in accordance with the requirements of the Act, and if the child is being educated in the regular classrooms of the public education system, should be reasonably calculated to enable the child to achieve passing marks and advance from grade to grade. In addition, this decision established the school district’s right to determine appropriate methodology. Bonadonna v. Cooperman, 619 F. Supp. 975, 1985–1986 EHLR DEC. 557:178, 183 (D. NJ 1985) NJ District Court judge reversed decisions of two administrative law judges in case of child with hearing impairment; found that the school district’s evaluations of Alisa fell “woefully short” because they relied solely on “subjective teacher observations” not objective or scientific test data. Issue turned on fact that only one assessment method was used, e.g., observation, stating that “such procedures lacked scientific validity, in that they were not systematic, were limited to a narrow range of behavior, and were not confirmed by recent test data”, thus discriminatory evaluation, i.e., evaluation that is biased, in this case, against deaf children. Honig v. Doe, 484 U.S. 305, 308 (1988)

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“Educational benefit” described as not just that the child must receive “any” benefit: the benefit must be “received” within the context of the child’s unique needs, not the needs of the agency. Deal v. Hamilton County Board of Ed, 6th Circuit TN (2006), 46 IDELR Zachary Deal, a high-functioning preschooler with autism would not receive FAPE and may digress in the school’s predetermined setting with a predetermined methodology; Court stated that “meaningful educational benefit must be gauged by the child’s potential”; “there is a point at which the difference in outcomes between two methods can be so great that the provision of the lesser program could amount to a denial of FAPE.” Will this lead to a new standard of FAPE as maximizing potential? Forest Grove SD v. T.A., 9th Cir. (2008) Parent provided intensive home support for their child who did not appear to meet IEP eligibility. During 504 meeting, parents expressed concerns for his LD/ADHD, concerns noted but not followed up on my schools. Parents placed him into private school, then sought reimbursement. Question: Can parents sue the school if it never had a chance to provide FAPE? Regarding RtI: If the school goes through RtI before eligibility can be established, can parents remove their child and seek private placement because there is no IEP? Is the school liable? District denied payment, 9th Circuit ruled in favor of parents, Supreme Court ruled in favor of parents October 2009. Endrew F. v. Douglas County School District (CO) (2017). U.S. Supreme Court Revisited the definition of FAPE stating that the IEP goals must be more demanding than “merely more than de minimis”: ■■ “The IEP must be reasonably calculated to enable a child to make progress appropriate in light of the child’s circumstances.” ■■ “The student’s educational program must be appropriately ambitious in light of his circumstances, just as advancement from grade to grade is appropriately am­ bitious for most children in a regular classroom. The goals may differ, but every child should have the chance to meet challenging objectives.”

Placement/LRE Letter to Siegel OSEP (1990) LRE must include placements options that for students with hearing impairment must include staff members who can interact with the child in his or her mode of communi­ cation. The EHA-B (Education for the Handicapped Act– Part B) contains regulations to ensure that children are assessed in their native language or appropriate mode of communication and that individuals providing special education and related services are adequately trained and qualified. OSEP clarified that the placement of a deaf or hearing-impaired

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child should facilitate interaction with language-appropriate peers and staff members who are skilled in the child’s mode of communication. Cobb County Board of Education, GA (1990) Placement at a school for the deaf was ordered because the school district’s recommended program failed to address the child’s need for a total communication environment. The School District of Philadelphia, PA—OCR (1990) The district did not have to provide speech therapy for a hearing impaired child by a certified speech therapist since the teacher of the hearing impaired, by virtue of her coursework in teaching speech to the deaf and district observations of her teaching skill, was sufficiently competent to meet the requirements of Reg. 104.33. Traverse City Area Public School, MI (1993) Because student who was deaf had an adequate IEP, continuation of the student’s program in total communication at a regular school was determined least restrictive rather than the parent’s request for placement at the state school for the deaf. Dreher ex rel. Dreher v. Amphitheater Unified School District, 9th Circuit Court (1994) Parents requested reimbursement for speech therapy services at a private school for their profoundly deaf child. The district’s program of oral methods and sign language was found to constitute FAPE, even though the parents did not choose that option. Anonymous letter to, 21 IDELR 67 (1994) Inquiry—What efforts have been made to ensure that the needs of children who are deaf are appropriate identified and met, and that placement decisions meet the standards of the IDEA and its regulations? Finding: Placement for students who are deaf must offer FAPE to meet LRE requirement Shapiro v. Paradise Valley School District, 35IDELR 187 (D. Ariz. 2001) Confirming an earlier finding, US District Court ruled that an out of state private school specializing in the education of children who are deaf and hard of hearing was an appropriate place for the student who had a cochlear implant. The court upheld an administrative award requiring the school to reimburse the parents for their placement costs. This case recognizes that there are different education and social needs of students with sensory impairments that must be considered when determining the instruction and services necessary to provide FAPE within LRE. D.D. v. Foothill SELPA 38 IDELR 29 (CA 2002) Ruled that the program developed by the staff of the early childhood program could not meet the needs of a child with a cochlear implant because the staff did not have sufficient training to work with this situation. Even though the district claimed that the private school provider could not meet all of the needs on the child’s IEP and that the private school setting violated natural environment requirements of Part C, the Administrative Law Judge ordered the SELPA

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to pay for the private school placement and reimburse the parents for past services provided at that center. C.M. v. Miami-Dade County School Board (2003) Parent of a 4-year-old child with a cochlear implant sought reimbursement for verbotonal therapy while attending a private school. The Administrative Law Judge ruled in favor of the district finding that the school had sufficiently trained staff to address the child’s verbotonal therapy needs and that the IEP was reasonable calculated to provide the student with meaningful educational benefit given her needs. J.C. v. California School for the Deaf, 46 IDELR 184 (CA, 2006) A deaf student with additional disabilities was discriminated against by CSDB by intentionally excluding her from classroom lessons and other activities due to her autism and cognitive impairments. The court rejected the district’s claim that the student lacked the ability to benefit from an education at CSDB. Cave v. East Meadow Union Free SD, IDELR 92 (2nd Cir, 2008) 504/ADA case in which a deaf student tried to bring his service dog to school, but 2nd Circuit said no, this is not on his IEP (schools claimed student allergy prohibition). Parents sued, but courts said parents should have tried to get this on the IEP, since they did not, they did not “exhaust their administrative remedies.” Issue: Is the dog required for FAPE? M.M. v. NYC Dept of Ed, 51 IDELR 128 (S.D.N.Y. 2008) Can 3-year-old “stay put” in IFSP if her parents do not like the IEP? No. The school district did not have to pay for the private early intervention program the parents elected to continue during a dispute over her initial IEP. Circuit Courts have varied on “stay put” with IFSP, but in this case, the ruling upheld OSEP’s official comments that districts have no obligation to fund Part C services when a parent disputes Part B plan. In this situation, the child was not considered to have a “current educational placement”; therefore, “stay put” did not apply.

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Related Services Anthony Wayne Local School District, Ohio (1990) Even though the child (actually two twin sisters) placed by parents at private, out-of-district school, the school district the child resided within remained responsible for providing related services at the private school. The district was also ordered to reimburse the parents for tuition to the private school since the district failed to provide the related service (individual and small group instruction) as required by her IEP, thereby denying the child FAPE. Letter to Dagley, OSEP (1991) Sign language instruction must be provided to parents (under “parent counseling and training”) if IEP team determines instruction for parents is necessary for the child to receive benefit from his education program.

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Benicia, CA Unified School District, OCR 30 IDELR 900 (1998) Plan resolved district’s obligation to provide audiologist and sign language interpreter. NOTE: Review IDEA 2004 OSEP comments for more clarification in this area.

504

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OCR 1988. Cleveland (OH) Public School District, 353:307. School district violated 504 when it failed to provide FM systems, individualized speech therapy, and sufficient interpreters in a timely manner. J.W. v. Fresno Unified SD, 50 IDELR 42, (E.D., CA 2008) A California district court agreed with the school dismissing the case regarding a student with a hearing disability on a 504 plan because he could not seek the legal remedies of the IDEA when he alleged that he had not been provided with a FAPE. Section 504 does not focus on the needs of the student based on his or her disabilities, but on the access to educational services.

Interpreter Services Zobrest v. Catalina Foothills School District, 9th Circuit Court, (1992), U.S. Supreme Court, (1993) The 9th Circuit Court in 1992 determined that the provision of an interpreter at public expense at a parochial school would violate the Establishment Clause of the U.S. Constitution (dealing with separation of church and state) because the interpreter would be required throughout the school day, for both education and religious instruction. The U.S. Supreme Court in 1993, however, ruled that the provision of interpreter services to students with disabilities at parochial schools is not barred by the U.S. Constitution as a matter of separation of church and state. This case only considered whether the Establishment Clause could bar the school district from providing a publicly paid sign language interpreter on the grounds that it was a religious school. Zobrest did not address the issue of whether private school students are entitled to such services under IDEA. Tugg v. Towey, FL (1994) The use of interpreters for counseling services for deaf and hearing-impaired individuals, including students, was found to be unequal to those provided to the general public. The Florida Department of Health and Rehabilitation Services was ordered to provide mental health services to individuals who were deaf by counselors with sign language skills and an understanding of the mental health needs of the deaf community. Cefalu ex re. Cefalu V. East Baton Rouge Parish School Board, LA (1995) The court ruled that IDEA regulations specifically required the board of education to provide a sign language interpreter to a student in the parochial school his parents had

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placed him, because unlike other special education services, the purpose of the sign language interpreter was to provide the student with assistance most of the time, a service that could be provided outside of the private school classroom. Fowler by Fowler v. Unified School District No. 259 KA (1995) The district was ordered to provide an interpreter at a private, nonsectarian school for the deaf student because there was agreement he needed the service and the district would have had to provide the service if he attended the public school. Because the district had provided services outside of its cluster site to other students, it failed to prove that doing so for this student at a private school would pose an unreasonable burden. Park City School District, UT (1995) The district was found to have no obligation to provide a cued speech transliterator for a deaf student in a parochial school since it could provide FAPE within the public school. The ruling indicated that neither IDEA nor EDGAR entitled a private school student to services that were essential to maintaining him in the private school placement

Other OSEP 1991. Letter to anonymous, 18 IDELF 627 State Board may not change IEP team’s determination. B.F. v. Fulton County SD, 51 IDELR 76 (GA 2008) Can the parent dictate to the school which teacher or staffer can work with their child? No, not even when the student suffers PTSD resulting from encounters with his case manager and para. Unfortunately, the parents did not document their concerns with the teacher/staff until they wrote a letter requesting homebound services (substantiated by a private psychologist’s opinion). Courts could not determine if the parent concerns were expressed simply as justification for their claim for homebound instruction.

Medical Services in a School Setting Bright-line test of medical services provided by a school compared to a physician; Courts distinguished medical services from related services by defining medical service as those provided by a physician and that any service by a nonphysician could be considered an educationally related service. Irving Independent School District v. Tatro, 648U.S. 883 (1984)School ordered to provide in-school catheterization services. ■■ Supreme Court in Cedar Rapids Community School District v. Garrett F., 526 U,S. 66 (1999). School was ordered to provide full-time nursing care in school to ventilator-dependent student; services not considered medical because it did not require a physician and could be done in school by a trained health provider. NOTE: Review IDEA 2004 OSEP regulations and comments for more clarification in this area. ■■

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12

Prevention of Noise-Induced Hearing Loss and Tinnitus in Youth With Deanna K. Meinke CONTENTS

Chapter 12

Epidemiology Estimates of Noise-Induced Hearing Loss in Youth Epidemiology of Noise-Induced Tinnitus in Youth Rationale for Hearing Loss Prevention Targeting Youth Public Health Role for Audiologists

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CONTENTS 

(Continued )

Raising Public Awareness in the School Setting Noise Awareness and Prevention Programs Education to Prevent Noise-Induced Hearing Loss Dangerous Decibels Hearing Screenings for At-Risk Individuals Advocating for Public Policies Challenges and Future Directions

KEY TERMS Noise-induced hearing loss, tinnitus, hearing health promotion, health communication, epidemiology of noise-induced hearing loss, youth, adolescents Chapter 12

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An estimated 5.9 million youths between the ages of 9 and 19 years of age have elevated hearing thresholds in the 3 to 6 kHz range suggestive of noise-induced hearing loss. Tinnitus is an early indicator of noise-induced hearing loss. Gradual-onset noise-induced hearing loss is insidious and develops into more severe hearing losses with long-term consequences without intervention to prevent progression. Audiologists have a role in public health efforts to prevent noise-induced hearing loss in youth and adults. Health communication science has contributed to the development of behavior change theories that have been incorporated into hearing health promotion programs. Evidence-based strategies to change knowledge, attitudes, and intended behaviors have been developed and can be implemented in the classroom.

Educational audiologists have a unique opportunity and professional obligation to advocate and support public health efforts to prevent noise-induced hearing loss (NIHL) and tinnitus in both youth and adults. The need for such prevention efforts is great despite recent epidemiological data suggesting that “kids [adolescents] hear better nowadays than we did” (Hoffman et al., 2019). Questions addressed in this chapter include the following: ■■ ■■

What are current trends in the prevalence of NIHL? How prevalent is tinnitus in youth?

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How do awareness campaigns and intervention programs differ? How should hearing screening and hearing loss prevention education interface? What are the challenges and suggested solutions to overcoming them?

EPIDEMIOLOGY ESTIMATES OF NOISE-INDUCED HEARING LOSS IN YOUTH National representative data on the hearing status of youth in the United States have been obtained by the U.S. National Center for Health Statistics since 1960 using a standardized measurement approach (CDC NHANES, 2009). The data collection included measuring hearing thresholds for both ears at frequencies of 0.5, 1, 2, 3, 4, 6, and 8 kHz in youth aged 12 to 17 or 19 years combined with demographic/survey questions (Hoffman et al., 2019). These data sets are periodically released and publicly available for researchers to further investigate hearing status and trends over time in U.S. civilian, noninstitutionalized youth. Early evidence of a NIHL has been identified as the presence of a notched audiometric configuration in airconducted pure-tone audiograms (Niskar et al., 2001). The presence of a “notch” requires that the audiogram meets the following three criteria: (1) threshold at 0.5 and 1 kHz are both 15 dB HL or less; (2) the maximum threshold at 3, 4, or 6 kHz is 15 dB higher than the highest (poorest) threshold at 0.5 and 1 kHz; and (3) the threshold at 8 kHz is 10 or more dB lower (better) than the maximal threshold at 3, 5, or 6 kHz. Niskar et al. (2001) reported 15.5% (95% confidence interval [CI]: 13.3% to 17.6%) of children aged 12 to 19 years with a noise-induced threshold shift (NITS) in one or both ears based on the National Health and Nutrition Examination Surveys (NHANES) III data collected between 1988 and 1994. Henderson, Testa, and Hartnick (2011) used the

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Call to Action Extrapolating the 12.8% prevalence to the 2018 U.S. youth census numbers suggests that at least 5.9 million youth aged 9 to 19 years have audiometric test results suggestive of early NIHL (U.S. Census, 2019). This estimate does not include the number of youths that demonstrate a HFHL that may have progressed beyond a notched audiometric configuration due to continued exposure to hazardous noise. Regardless of the count estimates, millions of U.S. youth would benefit from efforts to prevent the onset and progression of NIHL.

same NITS criteria as Niskar et al. (2001) and also included both low-frequency (0.5, 1, and 2 kHz) and high-frequency (3, 4, and 6 kHz) prevalence rates to investigate trends in the NHANES III data from 1988 to 1994 and NHANES 2004 to 2006. Hearing loss was defined as average thresholds greater than 15 dB HL in one ear. Henderson et al (2011) found no statistically significant increases in the rates of NITS, highfrequency hearing loss (HFHL) or low-frequency hearing loss (LFHL) between 1988 to 1994 and 2005 to 2006 cohorts. Their analysis reported 15.9% (95% CI: 13.55% to 18.2%) 12- to 19-year-old subjects had NITS in the 1988 to 1994 data set (comparable to Niskar et al., 2001) and 16.8% (95% CI: 13.9% to 19.7%) had NITS in the 2005 to 2006 data set. There was evidence of a significantly ( p = 0.0001) higher prevalence of NITS among female youths in the earlier data set (11.6% [95% CI: 9.0% to 14.1%]) when compared to the later data set (16.7%: [95% CI: 13.25% to 20.3%]). More recently, Su and Chan (2017) retrospectively analyzed the audiometric data from youth 12 to 19 years obtained in the NHANES III (1988 to 1994), NHANES 2005 to 2006, NHANES 2007 to 2008, and NHANES 2009 to 2010. Trends in the prevalence of NITS reveal an increasing prevalence from 15.8% in NHANES III to 17.5% in NHANES 2007 to 2008, and then decreasing to 12.8% by NHANES 2009 to 2010. (Table 4–3 summarizes these data.)

EPIDEMIOLOGY OF NOISE-INDUCED TINNITUS IN YOUTH A systematic review of tinnitus prevalence estimates was published by Rosing, Schmidt, Wedderkopp, and Baguley (2016). Across studies, the prevalence of tinnitus among children in the general pediatric population with normal hearing varied from 5.4% to 46%. The prevalence increased to 23.5% to 62.2% among children with hearing loss. Researchers from the Children’s Hospital of Colorado con-

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ducted a 10-year (2003 to 2013) retrospective review of electronic health records and follow-up telephone survey methods to describe the clinical features and natural history of tinnitus in a pediatric otolaryngology clinic setting (Chan, Jensen, & Gao, 2018). One-hundred-eighty pediatric patients (≤18 years of age; m = 11.5 years) were identified who presented with a primary complaint of tinnitus and who also had pure-tone audiometry results. The majority (77.8%) of the subjects with tinnitus had normal hearing (unspecified criteria), and 9.4% had sensorineural hearing loss. The remaining had conductive or mixed hearing conditions. Noise exposure was identified as the underlying etiological factor in 7.2%, head trauma in another 7.2%, and remained unknown in 47.2%. These authors specifically noted that opportunities for preventing pediatric tinnitus include addressing the risk of hazardous noise exposure and head injury in youth. Tinnitus is a well-recognized indicator of hazardous sound overexposure (Griest & Bishop, 1998) and occurs in adolescents after high-level sound exposure (Chung, Des Roches, Meunier, & Eavey, 2005; Gilles, Van Hal, De Ridder, Wouters, & Van de Heyning, 2013; Jokitulppo, Bjork, & kaan-Penttila, 1997; Mercier & Hahmann, 2002; Zocoli, Morata, Marques, & Corteletti, 2009). Estimates range between 45% and 77% of adolescents reporting temporary tinnitus and hearing loss after loud music exposure. Gilles et al. (2013) surveyed 3,892 high school students regarding the prevalence of temporary and permanent tinnitus and administered the Youth Attitudes to Noise Scale (Widen & Erlandsson, 2004) and the Beliefs About Hearing Protection and Hearing Loss (Stephenson & Stephenson, 2011) questionnaires. The prevalence of temporary tinnitus was 74.9% and permanent tinnitus was 18.3% in this high school population. The prevalence of temporary tinnitus increased with age. The majority of students had a “neutral attitude” toward loud music. Only 4.7% reported using hearing protection, and in general, their knowledge about the risks of loud music was reported to be extremely low. Gilles et al. (2013) stressed the importance implementing prevention efforts that focus on tinnitus as a warning signal for noiseinduced auditory damage and highlighted the connection between temporary and permanent noise-induced tinnitus for these students.

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Prevention of Noise-Induced Hearing Loss and T   innitus in Youth

RATIONALE FOR HEARING LOSS PREVENTION  TARGETING Y   OUTH While preventing NIHL and tinnitus in youth provides a clear rationale for prevention efforts, the importance is fur­ ther underscored by considering the long-range implications for youth when incurred at a young age. Educational audiologists are well acquainted with the academic ramifications of even a slight or minimal hearing loss (Bess,

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Dodd-Murphy, & Parker, 1998; Gustafson, Key, Hornsby, & Bess, 2018), but perhaps less well known are the longterm implications in terms of future job opportunities, quality of life, and long-term costs of living with NIHL. Sixteen percent of 2,526 young workers aged 17 to 25 years had HFHL when beginning employment between 1984 and 2004 (Rabinowitz, Slade, Galusha, Dixon-Ernst, & Cullen, 2006). Hearing loss was defined as hearing threshold >15 dB HL at 3, 4, or 6 kHz in either ear. Audiometric notches consis­ tent with noise exposure were found in approximately 20% of the subjects and remained essentially constant over the 20-year period of study. Although stable, the fact that onefifth of young adults start work with NIHL suggests a need for greater public health efforts. Young military recruits may be medically disqualified based on medical conditions that may “reasonably be expected to prevent or interfere with the proper wearing or use of military equipment (including hearing protection)” and includes the following conditions (U.S. DoD Instruction 6130.03, 2018): ■■ ■■

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■■ ■■ ■■

■■ ■■ ■■ ■■

■■

atresia of the external ear or severe microtia; congenital or acquired stenosis; chronic otitis externa; severe external ear deformity; history of Ménière’s syndrome or other chronic diseases of the vestibular system; history of any surgically implanted hearing device; history of cholesteatoma; history of any inner or middle ear surgery; current perforation of the tympanic membrane or history of surgery to correct perforation during the preceding 180 days; or chronic eustachian tube dysfunction with the last 3 years as evidenced by retracted tympanic membrane, or recurrent otitis media, or the need for pressure-equalization tube.

Recruits may also be medically disqualified if hearing thresholds exceed the values in Table 12–1 or if a hearing aid is worn. Gubata, Packnett, Feng, Cowan, and Niebuhr

(2013) found that 19.6% of new-recruit audiograms were eligible for medical disqualification unless a medical waiver was granted. Many workplaces (military, firefighting, coast guard, law enforcement and aviation) require effective communication skills as a crucial requirement to ensure safe and effective operations (Giguére et al., 2008). Adolescents with NIHL may unknowingly experience limitations with regard to their career options upon graduation. NIHL in youth is insidious and cumulative over time without intervention (Folmer, Griest, & Martin, 2002; Lass, Woodford, Lundeen, Lundeen, & Everly-Myers, 1986). Folmer et al. (2002) noted that a mild HFHL in a 16-year-old high school student may deteriorate into a debilitating level later in life. The economic cost of hearing loss in the United States has been estimated by Neitzel et al. (2017) using underemployment and wage differentials as a function of hearing status based on the work by Jung and Bhattacharyya (2012). They estimated that those with hearing loss were 2.5 times more likely to earn less (25% less) than individuals with typical hearing. A range of $58 billion to $152 billion (core estimate of $123 billion) could be saved annually if hearing losses attributed to hazardous noise exposures were prevented (Neitzel et al., 2017). These costs do not include health care, special education costs, lost quality of life, tinnitus, and caregiver contributions, and they did not consider the potentially positive impact of hearing aids or cochlear implants. Recent research into cochlear synaptopathy also called “hidden hearing loss,” suggests that hazardous noise exposure at young ages in mammals has long-lasting implications for auditory system dysfunction later in life (Kujawa & Liberman, 2015). Audiologists are also at a disadvantage since audiometry and otoacoustic emissions are insufficient for the early detection of cochlear synaptopathy in humans. Kujawa and Liberman (2015) expressed concern that the risk of hidden hearing loss from both recreational and occupational sources is not fully appreciated and may be more detrimental than initially thought. They also noted that federal regulations for daily allowable workplace noise expo-

TABLE 12–1  U.S. Department of Defense Medically Disqualifying Audiometric Criteria (DoD Instruction 6130.03, 2018) Frequency (Hz)

Average Thresholds (both ears) (dB HL)

Maximum Threshold (either ear) (dB HL)

500

>25

>30

1000

>25

>30

2000

>25

>30

3000

No standard

>35

4000

No standard

>45

6000

No standard

No standard

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Prevention of Noise-Induced Hearing Loss and T   innitus in Youth

PUBLIC HEALTH ROLE FOR  AUDIOLOGISTS The American Public Health Association states that “Public health promotes and protects the health of people and the communities where they live, learn, work and play” (APHA, 2019). The APHA notes that public health “saves money, improves our quality of life, helps children thrive and reduces human suffering.” Certainly, educational audiologists recognize the importance of the school environment as a gateway to reaching students and their parents as well as an opportunity to help students thrive and learn lifelong lessons to encourage hearing health. In the United States, hearing loss prevention is integrated into audiology scope of practice (SOP) documents. Professional audiology associations develop SOP documents to establish boundaries for which audiologists are considered competent, based on their education, training, and experience. Hearing loss prevention or hearing conservation is acknowledged in the SOPs published by the American Academy of Audiology (AAA, 2004), the American SpeechLanguage-Hearing Association (ASHA, 2018), and the Educational Audiology Association (EAA, 2019) (see Appen­ dix 2–C). EAA specifically note that educational audiologists are responsible for ■■

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educating students and school personnel about the prevention of hearing loss; and managing school programs for hearing loss prevention education.

The audiologist’s role in public health is also stated in federal laws. The Individuals with Disabilities Education Act (IDEA) (https://sites.ed.gov/idea/statuteregulations/#statute) identifies creation and administration of programs for prevention of hearing loss within the definition for audiology.1 Healthy People 2020 (https://www.healthypeople.gov/2020 /topics-objectives) also stipulates national goals related to prevention of NIHL in adolescents—reducing the proportion of adolescents with NIHL, increasing the use of earplugs/earmuffs in adolescents, and integrating hearing loss prevention topics into school-based education. New goals

for 2030 will be forthcoming and are expected to also include hearing health goals for schools and youth. Themann (2016) summarized 1,811 survey responses from audiology members of the ASHA in 2014. Audiologists recognize their role in public health in several contexts: (a) raising public awareness regarding the importance of good hearing to overall health, (b) educating others about hearing and balance risk factors and strategies to prevent hearing loss and falls, (c) providing hearing screenings for at-risk or underserved populations, and (d) advocating for public policies that support hearing loss prevention efforts and access to intervention.

RAISING PUBLIC AWARENESS IN THE SCHOOL SETTING Raising awareness will not necessarily change health behaviors, but it is a starting point for encouraging individuals to consider their hearing health, identify potential risks, and realize the need for behavior change. It is well understood that individuals must recognize their own vulnerability and susceptibility to a health condition before steps are taken to change behavior. Simple efforts that can be undertaken in this regard include school announcements prior to sporting or music events at the school reminding students to protect their ears, posters/infographics regarding NIHL, and strategies for prevention.

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sures are flawed, since they all rely on the assumption that complete hearing threshold recovery indicates full cochlear recovery. They further stated that noise is a much more dangerous environmental hazard than originally thought. Beyond the obvious health benefit, the prevention of NIHL in youth encompasses long-term improvements in academic achievement, improved quality of life, enhanced career opportunities, and economic savings.

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Noise Awareness and Prevention Programs The U.S. Department of Health and Human Services promotes a public campaign entitled “It’s a Noisy Planet” designed to increase awareness among parents of children 8 to 12 years of age about the causes and prevention of NIHL (https://www.noisyplanet.nidcd.nih.gov/). A review of the program is provided by Figg (2018). Adopt-A-Band is an awareness program targeting young musicians provided by Etymotic Research Inc. (https://www .etymotic.com/hearforalifetime/adopt-a-band). Auchter and Le Prell (2014) demonstrated that the campaign increased the use of flat-attenuation earplugs in members of two high school marching bands. However, the authors noted that selfreported behavioral change was low at the end of the school band season. Dangerous Decibels has found great success with the Jolene educational mannequin (http://dangerousdecibels .org/jolene/) (Martin & Martin, 2008). A Jolene (shown in Figure 12–1) is a system for approximating the sound level of personal audio devices (e.g., smartphones). Jolene has a

1

34 CFR §303.13(b)(2)(iv) and §300.34(c)(1)(iv).

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FIGURE 12–1  Jolene being used at a community event to educate youth and adults about safe listening levels.

modified sound level meter wired to a silicone ear. Listeners can set their preferred listening level when listening to their own music and then remove their headphones/earphones and place them on Jolene. The sound level meter attached to the Jolene will then provide an estimated listening level that can be used by the Jolene handler to determine the safe listening duration. The listeners can also learn at what volume control listening becomes unsafe/safe depending on their chosen level. Older students have great fun building Jolenes using the Jolene cookbook and teaching younger youth. Jolenes have been used in peer-reviewed scientific research (Levey, Levey, & Fligor, 2011; Park, Guercio, Ledon, & Le Prell, 2017), science fairs, and has recently been incorporated in a permanent exhibit at the Musical Instrument Museum (https://www.bizjournals.com/phoenix/news/2018/01/25 /mim-debuts-its-new-stem-gallery-showing-connection.html). Jolenes can also show up at school events and help inform parents, teachers, and students. It is important to note that the Jolene measurement system is a tool to increase awareness and is not an exact measure of ear canal sound pressure levels (Berger, Megerson, & Stergar, 2009). More precise clinical methods are available to audiologists to measure the real ear sound levels using microphone-in-real-ear techniques when evaluating and counseling patients (Portnuff, Fligor, & Arehart, 2013).

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EDUCATION TO PREVENT NOISE-INDUCED HEARING LOSS Knowledge is easy to change, especially in the short term. Long-term behavioral change is much more challenging to accomplish. Behavior change theories inform health promotion and intervention (National Cancer Institute, n.d.), and these theories have been incorporated into evidencebased hearing health intervention programs targeting youth

Hearing loss prevention programs targeting youth should be oriented toward the target audience, use interactive (not passive) instruction, incorpo­ rate skills-based learning, and use appropriate sci­entific content. Educational audiologists are encouraged to review the literature for programs founded on theory with evidence-based outcomes that result in intended or self-reported behavioral change (Meinke, Martin, Griest, Howarth, Sobel, & Scarlotta, 2008).

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Prevention of Noise-Induced Hearing Loss and T   innitus in Youth

Dangerous Decibels The core of the resources from Dangerous Decibels is the classroom program (Martin, 2008). Several health communication theories guided the development and evaluation of the program (Sobel & Meikle, 2008). These theories include the Transtheoretical Model (also called the Stages of Change), the Theory of Reasoned Action, the Theory of Planned Behavior, the Health Belief Model, and the Social Cognitive Theory. More recently, the program has been evaluated in the context of the Socio-Ecological Model (McLeroy, Bibeau, Steckler, & Glanz, 1988; Reddy, Welch, Ameratunga, & Thorne, 2017). The 45- to 50-minute program can be adapted for K–12 students, adults, and special populations (musicians, military, recreational firearm users). The program consists of nine interactive modules that guide the students through the exploration of (a) the sources of hazardous sound exposure, (b) the consequences of hazardous noise exposure, and (c) strategies to prevent NIHL and tinnitus. The program is designed for anyone with an interest in hearing health promotion to be trained as a classroom educator. The training of educators is delivered in 2-day workshops that train, prepare, and equip individuals to be able to deliver the program immediately after successfully completing the training. Workshop information can be obtained by visiting the Dangerous Decibels website.

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Nuggets from the Field When teaching about hearing loss prevention, my trusty favorite is the Dangerous Decibels online tool.

Griest, Folmer, and Martin (2007) demonstrated the effectiveness of the Dangerous Decibels program in 1028 fourth- and seventh-grade students (both intervention and control groups). The fourth-grade cohort demonstrated improvements in knowledge and attitudes immediately after program delivery and 3 months later. The seventh-grade students also exhibited immediate improvements in knowledge and attitudes; however, the improvement in attitudes regressed to baseline 3 months postpresentation. Subsequent research used a randomized control trial design to compare four intervention approaches: (a) the Dangerous Decibels classroom program taught by school nurses, (b) the Dangerous Decibels classroom program taught by older peer educators (high school students), (c) self-guided exploration of the Dangerous Decibels museum exhibit at the Oregon Museum of Science and Industry, and (d) self-guided exploration of the online Dangerous Decibels virtual exhibit (http://dangerousdecibels.org /exhibit/virtual-exhibit/) (Martin, Griest, Sobel, & Howarth, 2013). Outcomes from 53 fourth-grade classrooms (1,120 students) found that all interventions produced significant improvements, but the number of improvements decreased over time (baseline, to postpresentation to 3 months post). The classroom programs were more effective than the Internetbased virtual exhibit and the museum exhibit. Using high school students to deliver the program to younger students also contributes to changes in knowledge, attitudes, and intended behaviors in this hard-to-reach adolescent population (Martin et al, 2013; Welch, Reddy, Hand, & Devine, 2016). Regardless of the initial outcomes, ongoing booster interventions are needed to support the long-term outcomes. The robustness of the Dangerous Decibels program when adapted and translated for global audiences has resulted in similar outcomes in youth from New Zealand, Brazil, Singapore, and China (e.g., Knobel & Lima, 2014). Currently, the program is being integrated into “serious gaming” with the goal of integrating technology, STEM (science, technology, engineering, and mathematics) learning, and hearing health promotion.

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(Meinke & Martin, 2017; Sobel & Meikle, 2008). Educational audiologists are encouraged to review the literature for programs founded on theory with evidence-based outcomes that result in intended or self-reported behavioral change. Neufeld et al. (2011) reported that the Sound Sense from the Hearing Foundation of Canada (http://soundsense.ca/) significantly improved earplug use practices in 775 sixthgrade elementary school students. The authors did not report the theoretical basis of the intervention that consisted of a 45-minute session in which trained personnel covered “aspects of the hearing mechanism, anatomy of the ear, etiology, signs, and consequences of NIHL, and hearing conservation practices.” The program incorporates discussion, sound level meter measurements of their audio players, and a 10-minute video of an animated character inside the hearing organ. Students are left with earplugs and stickers at the end of the presentation. Neufeld et al. (2011) did not report changes in knowledge, attitudes, and behaviors other than self-reported earplugs use. Although the improvement in earplug use was statistically significant, the actual percentages of youth reporting the use of earplugs as “always or sometimes” at music-related events (dances, rock concerts, percussion instrument, and electric guitar) were maximally 7.9% and 7.5% for “other noises” for the treatment group. The majority of youth were not wearing earplugs, and Neufeld et al. (2011) stated that the rates of improvement in earplug use were “1–6% at 2 weeks post intervention, and 1–3% at 6 months post-intervention.” (p. 180)

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HEARING SCREENINGS FOR AT-RISK INDIVIDUALS Hearing screening provides an opportunity to identify students with hearing differences and is addressed in Chapter 4.

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It is difficult for hearing screening programs to detect NIHL in the early stages when intervention is most critical. Meinke and Dice (2007) found that the majority of school-based hearing screening protocols used in the United States would identify only 22% of students with a high-frequency notched audiometric configuration suggestive of NIHL. Children participating in noise hazardous activities will need hearing threshold testing to detect NIHL and monitor their hearing status. Extended high-frequency audiometry and otoacoustic emissions are also useful for these same purposes. Meinke, Meade, Johnson, and Jensema (2008) described the feasibility and practicality of using an occupational model of automated audiometry for identifying and monitor­ing youth with NIHL. Advanced technology and boothless audiometry offer new options for educational audiologists (Meinke et al., 2016). Teachers, coaches, and maintenance and food service staff employed in the school setting may also be noise exposed. The school district may be responsible for providing regulatory required hearing conservation programs according to the Occupational Safety and Health Administration (OSHA, 1983) or best-practice hearing loss prevention programs based on the National Institute of Occupational Safety and Health (NIOSH, 1998) recommendations. School hearing screenings will not adequately monitor these workers, and the educational audiologist may be asked to support these hearing conservation needs (Johnson & Meinke, 2008). Hearing screenings may also provide a unique opportunity to reinforce the benefits of healthy hearing. Most students pass the school hearing screening, and educational audiologists are encouraged to leverage this outcome to reinforce the value of good hearing and strategies to keep it that way. Perhaps screening results can contain positive hearing health messages for the families. Students can be encouraged to design healthy hearing posters to be on display during the hearing screenings. Proper earplug use can be demonstrated and taught at the time of the screenings while students are waiting their turns. This is also an opportune time to implement Jolene.

Schools offer an ideal setting to implement strategies to target all of these influencing levels. For instance, parentteacher associations might communicate hearing health messages to parents, raise money for educator training and/ or provide earplugs; clubs within the school may work to eliminate or reduce noise exposures at the school; school newspapers and social media can be used to communicate hearing health messages throughout the year; and school policies could be developed to promote safe environments (e.g., music levels at dances). Curriculum changes at the district and state levels could be reviewed, and hearing health promotion could become an expected classroom topic. Small efforts at each level will gradually shift the culture, and the school will become a place where hearing is valued, and individuals are able to easily implement the strategies that will promote healthy hearing.

CHALLENGES  AND FUTURE DIRECTIONS Researchers and U.S. government agencies have been demonstrating the need for hearing conservation education directed toward youth since the early 1940s. Unfortunately, the need is still ever present, and millions of youth are at risk of NIHL. There are many challenges to overcome for hearing loss prevention to become an integral part of the educational audiologist’s job duties. Perhaps we should start by considering the reasons for this situation highlighted by Folmer et al. (2002): ■■

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ADVOCATING FOR PUBLIC POLICIES The socioecological theory of health promotion recognizes the importance of interventions targeting not only the individual at risk but also the circles of influence around the individual. Educational audiologists can advocate for policies that support hearing loss prevention efforts and access to intervention. These include interpersonal relationships (family, friends, social networks), institutional or organizational influencers (schools, workplaces, health care facilities, faithbased groups), community influencers (local media, leaders), and public policy (national, state and local laws, rules).

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First, there is a lack of public awareness about how excessive noise damages the ear and the consequences of hearing loss. If school administrators, teachers, and parents are not aware of the risk and strategies to ameliorate the risk, then it is unlikely that resources will be committed to hearing conservation efforts. Second, lack of effective dissemination of existing hearing loss prevention programs in the schools. There is no systematic way to integrate hearing health promotion into all classrooms. Dissemination of existing evidencebased programs relies on a key individual(s) to champion the effort and develop a grassroots effort in their own communities. Teachers and audiologists frequently do not have the resources to purchase materials or attend training sessions. Third, hearing health promotion efforts are not sustained if the key individual retires, moves, or becomes unavailable. Department of Education and Health Department agencies should be approached to help develop the strategies that would support effective and ongoing dissemination of evidence-based programs. Classroom time is in high demand for both academic purposes and health education, but health education

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Prevention of Noise-Induced Hearing Loss and T   innitus in Youth

What can be done to overcome these barriers? 1. Begin by raising public awareness about high-level sound exposure risks, how hearing can be damaged, the consequences of NIHL and tinnitus, and the success of prevention programs. 2. Run a pilot project to identify the number of students with early indicators of NIHL and compare with national prevalence rates. This may help justify the need for hearing health promotion at the local level. 3. Ask for your job duties to include hearing loss prevention activities. If administrators do not hear the requests, the need will not be addressed now or in the future. 4. Write a local grant or coordinate a training workshop for audiologists, teachers, high school students, or volunteers to become trained and equipped to provide an evidence-based intervention program in your schools.

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5. Work with parent organizations and administrators to control hazardous noise sources and reduce exposures at school. 6. Partner with local industry to underwrite the cost of program personnel and supplies; many of them have experts in hearing safety and may be willing to support efforts to have a future workforce with undamaged hearing. 7. Last, seek a mandate from local school boards or state or federal legislators to support the implementation of hearing health promotion in K–12 classrooms. Ultimately, educational audiologists have an ethical obligation to promote hearing health and care for at-risk students. We have a long road ahead to change the environment and our culture regarding hazardous sound exposure. Yet, working together to communicate the need and address these challenges is the best way forward. Perhaps you will think creatively and become the hearing champion in your school and help open the ears of others to the importance of hearing health promotion. It is time we change the course of the past 75 years and fully address the need for hearing health education targeting youth and ultimately reduce the risk of NIHL in children and adults.

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topics tend to be a lower priority. Fortunately, hearing health messages contain many STEM-related concepts, and this may help motivate administrators and teachers to dedicate class time to the topic.

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SECTION II

COLLABORATIVE PRACTICES AND PROGRAM EFFECTIVENESS

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CHAPTER

13

Supporting the Educational Team With Carrie Spangler

CONTENTS

Chapter 13

Formal Inservice Preparation ■ Presentation ■ Follow-Up ■ Continuing Contact With Participants Coaching and Mentoring Educational Coaching ■ Coaching for Educational Audiologists ■ Mentoring

“Check your volume when listening to music.”

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Chapter 13

CONTENTS 

(Continued )

Summary Suggested Readings and Resources Appendices 13–A Inservice Outlines (Text) 13–B Inservice and Hearing Simulation Resources (Text) 13–C Sample Index Card Handouts (Text/Online) 13–D Inservice Evaluation Form (Text/Online) 13–E Sample Coaching Concept Organizer (Text)

KEY TERMS Inservice, coaching, mentoring, audience effects, teaming

KEY POINTS ■■

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Chapter 13

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Inservice typically targets job-specific information or skills related to needs in the present job situation. Inservice often focuses on information not adequately addressed in earlier adult and preservice education programs. Inservice sessions in educational audiology typically are time-bound formal presentations that can benefit adult learners by increasing awareness of listening and communication difficulties in education, prevention strategies, referral procedures, and classroom acoustics. Coaching incorporates building relationships, effective communication, supporting goals, and reflection. Mentoring in education involves a relationship between two people in the same or similar professions, where the mentor plays a supportive and advisory role for the individuals being mentored (i.e., mentees), in their current job settings. Combining coaching models with educational audiology inservice presentations creates a culture of adult learning in which new and advanced knowledge is learned, information is connected to meaningful learning situations, and teacher and staff become engaged and begin to develop appropriate instructional and support strategies on their own. A variety of models including inservice, coaching, and mentoring can be used to accomplish voluntary or required professional development in education and other professional fields.

An increasing number of deaf and hard of hearing students are spending the majority of their time in general education classrooms where many teachers have no background

or experience with the challenges that hearing and listening difficulties present for our students. While the role of educational audiologists in supporting student learning has not changed, our responsibilities and strategies of support for educational team members in a variety of educational settings may require a combination of approaches for improving student outcomes. Creating a culture of adult learning is necessary for teachers to understand and implement what we want them to know and apply. Adult learners who are actively engaged in the learning process where new knowledge is connected to meaningful situations learn more. Regular systematic feedback regarding the learning helps the adult learner adjust to ensure he or she is gaining the knowledge wanted and needed to meet individual goals (McDonough, 2013). This chapter describes traditional inservice development for presenting information to educational team members followed by materials related to a coaching philosophy and mentoring approach applied to ongoing support for classroom teachers. Finally, a combination of these

The 40th Annual Report to Congress on Imple­ mentation of the Individuals with Disabilities Edu­ cation Act (IDEA, 2018) reported 61.3% of deaf and hard of hearing students on Individualized Educa­ tion Programs (IEPs) spent 80% or more of their time in the general education classroom, another 15.5% spent 40% to 79% of their time in the gen­ eral education classroom, resulting in 76.8% of DHH students receiving most of their education in the general education classroom. This number does not account for students served on Sec­ tion 504 plans, all of whom receive all of their edu­ cation program in the general education classroom.

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Supporting the Educational Team

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What activities should be completed when planning and preparing for an inservice? What techniques make inservice presentations interesting and effective for the target audience of adult learners? What strategies are helpful in maximizing carryover of information and implementing strategies that have been presented? What is coaching, and how can it be used as a tool to maximize adult learning to support deaf and hard of hearing students? What characteristics facilitate successful coaching and mentoring in education? How can teachers, as well as students, benefit from relationship-based support systems?

FORMAL INSERVICE The word inservice typically is used within the field of American education to refer to training or education sessions provided to school personnel after they have accepted or are already working in a specific job. Inservice content usually targets job-specific information or skills related to needs in the present job situation that were not addressed in detail in the employee’s preservice education, that is, education that took place before the individual was hired. Although inservice was initially used as an adjective in conjunction with the word training, common usage has been shortened to the single word inservice as it is used throughout this section. Inservice sessions are typically one approach provided for voluntary or employer-required professional development/ continuing education for their employees. Professional development such as formal inservice ses­ sions and coaching activities should be provided for all educational staff working with one or more students who are deaf or hard of hearing. In addition, all school personnel can benefit from information provided via inservice to increase their awareness of pediatric hearing and listening difficulties, prevention strategies, referral procedures, and classroom acoustics. The importance of auditory function in traditional and dynamic learning environments, as well as social interaction and development, is often overlooked. Inservice sessions can be a relevant reminder of these factors even if there are no identified deaf or hard of hearing students within a specific school building or district. Frequent conferences and numerous publications are available to assist individuals in developing and improving the skills necessary to present information in workshop or inservice formats (see Suggested Readings and Resources). This section gives suggestions specifically for educational

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Inservice in education is problem-centered, learneroriented, and time-bound with activities and infor­ mation intended to develop a sense of purpose, broaden perception of students and their needs, and increase capacity to gain knowledge and facili­ tate mastery of techniques.

audiologists whose responsibilities include providing inservice for school staff. Three major phases are essential in the development and delivery of inservice sessions: preparation, presentation, and follow-up.

Preparation Educational audiologists have a wealth of information to share with their colleagues. Preparation is critical to determine what, when, and how much information to share within a given inservice session. These decisions should be based on knowledge of service schedules, target audiences and their existing level of knowledge, and current student needs. Organization of materials, equipment to be demonstrated, as well as preparation of technology and the facility can help to make more efficient use of inservice time during the actual session. Specific strategies to facilitate planning for educational audiologists are described in the following sections.

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approaches is discussed and recommended for facilitating educational support for deaf and hard of hearing students. This chapter addresses the following questions:

461

Scheduling The educational audiologist should find out if the school building or district has a formal inservice schedule. If so, identify the individual who oversees this schedule and ask him or her what procedure is required to be added to the schedule. Preplanning days are often used for inservice, but teachers may not have much time or interest in formal presentations during this period. Individual or small group inservice meetings can be more effective if short time periods are available. An alternative approach would be to request 15 minutes with the entire school faculty and staff. Within this limited amount of time, a brief description of educational audiology services and the educational audiologist’s role, the importance of hearing for classroom learning, student characteristics that suggest a need for referral, and current referral procedures with contact information and referral forms as handouts may be all you can cover. If deaf and hard of hearing students have already been identified, include an overview of the impact of varying degrees of hearing and listening challenges in the classroom, a brief review and handout covering possible classroom and instructional accommodations (e.g., “Tips for the Classroom” from Gallaudet University, 2015. See Appendix 13–C), and end with

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TIP: When presenting to entire faculty, manipulate the volume or on– off switch for the microphone and have a slide in the background that shows differing levels of visual clarity as a visual reinforcer of what stu­ dents with hearing challenges might miss.

a short question and answer time for those who have had students with hearing and listening challenges in the past to share strategies that worked for them.

Targeting the Audience

Chapter 13

Familiarize yourself with the audience and their reasons for attending. If the audience consists of teachers who are required to be there for professional development credit, the educational audiologist will need to plan techniques to involve them or pique their interest in the topic before presenting key information. Have these staff members heard information on hearing previously, and have most of them been involved with deaf and hard of hearing students in the past? If so, the information provided should be different than that given to an audience receiving materials for the first time. If the educational audiologist is new to the school system or if there has been a significant change in school personnel, a brief needs assessment of the target audience can help to describe prior knowledge of and experience with the topic(s) being considered. What is the group size? A group of 12 to 15 people is excellent for audience participation, and smaller groups can have relevant discussions and brainstorm while completing hands-on activities. Audience questions and comments in larger groups can cause presenters to lose focus and make it more difficult for each attendee to feel closely involved in the topic. Larger group problem-solving requires a method of quickly recording suggestions (e.g., Smart Board, chart paper) and a recorder with legible writing who can synthesize information on the spot. As noted previously, large

TIP: Give the unfair hearing test (https://successfor kidswithhearingloss.com/for-professionals/dem onstrations-simulated-listening-with-hearing-loss -devices/) instead of describing difficulties with ac­ cessing classroom instruction.

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group audiences typically will require planning for only a short period of time, so have critical information summarized and supported with visual and auditory experiences that grab attention and will be remembered. Adults have varied learning styles, so have several different strategies in mind for critical points you wish to have the audience take away. Some individuals respond and retain visual information more readily than auditory information, some the reverse, and some individuals benefit from a combination. As already noted, actively involving the audience typically enhances learning and retention, and personalizing information makes it more likely to be retained. Key principles for effective adult learning were identified at the University of Washington School of Public Health (2014) and are described in Table 13–1. Additional information on techniques and strategies to maximize adult learning can be found in Cockrell, Cap­ low, and Donaldson, (2000); McCarthy (2000); Peterson (2019); University of Washington, Northwest Center for Public Health Practice (2014); U.S. Department of Education (2011).

Selecting Content Knowledge of the target audience, together with current student needs, can help in selecting content that should be practical and personalized as much as possible. The educational audiologist should prioritize information and determine what is critical to present orally and what information can be given in writing for later review and follow-up. For example, if a remote microphone (RM) system will be used for the first time immediately after the inservice, it would

I hear and I forget. I see and I remember. I do and I understand.” Confucius (551bc– 479bc)

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TABLE 13–1  Key Factors for Effective Adult Learning ■■

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Learning environment feels safe and comfortable for learners to participate Material is immediately recognized as useful to learners Learning objectives are based on learners’ needs, interests, and skill levels Presentation engages and actively involves learners Presenter is respectful and recognizes the unique histories and characteristics of learners Presenter encourages learners to share experiences Coaches work collaboratively with learners to select methods, materials, and resources for instruction

Note. From U.S. Department of Education, TEAL Center Staff (2011) and Univer­ sity of  Washington School of Public Health (2014).

TABLE 13–2  Suggested Inservice Topics ■■ ■■

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Introduction to hearing loss Overview of the district’s audiology and deaf and hard of hearing program Effects of hearing status on learning Strategies to support deaf and hard of hearing students Social-emotional impact of atypical hearing Integrating auditory skill development into the classroom Students with hearing challenges in general education Management/maintenance of personal hearing instruments and/or cochlear implants Use of remote microphone technology in the classroom (RM) Hearing assistance technology (HAT; DM/FM) Communication modes and methods Deaf culture Working with classroom support personnel (e.g., tutor, interpreter, notetaker) New technologies in hearing assessment Prevention of hearing loss Early hearing detection and intervention (EHDI) Unilateral and minimal hearing challenges Classroom strategies for auditory processing difficulties Hearing screening Classroom acoustics Collaborative services; roles of the ED Aud, SLP, and TOD

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TIP:  Adults will stay more involved when you vary methods used to present material and include in­ teraction and physical or mental activity every 15 to 20 minutes.

Organizing Inservice Sessions Develop an Outline  After the topic has been selected, the audience is known, and the time has been defined, the educational audiologist should identify the objectives and develop an outline for this session. The time allotted for each subtopic or activity should be estimated; this is especially crucial if time is of the essence, as it always seems to be in a school system. The longer the inservice session, the more need for a variety of presentation methods. A general rule of thumb to consider when planning is that there should be interaction and physical or mental activity every 15 to 30 minutes for maximum involvement in adult learning. Collaboration in which attendees work together as a team in a problem-based learning format has been demonstrated to enhance adult learning and retention (NaeveVelguth, Hariprasad, & Lehman, 2003), but ensuring that all members of each team are actively involved can be challenging. Breaking into small groups where participants have to change their seats may use up precious time in a short inservice session, so include a quick strategy for designating team members (e.g., counting off, use of table talk where participants at the same table form the group) in your plan. Use of polling with participants using their phones or clickers to vote is a quick and easy way to get participants to answer targeted questions and stimulate discussion. Because many participants in inservice sessions like to have an outline of the presentation with space to take notes, consider a handout. Sample outlines for various inservice topics can be found in Appendix 13–A.

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be critical that all school staff see and listen to this system to recognize it and to understand its purpose, benefits, and limitations. Only teachers using the system would need to have information on current operation, monitoring, and maintenance. Table 13–2 lists a variety of suggested inservice topics for educational audiologists that can be useful with differing audiences and time schedules.

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Select Materials  Collect more materials than you plan to use and then divide them into those that are essential for the topic and those that can be put aside to refer to if there is extra time. Materials, portable test equipment, personal hearing instruments, FM/DM receivers, RM HAT systems, and supplementary videos can also be shown or links can be made available for individual perusal at a later time. In our experience, extra materials are rarely looked through after the inservice session has concluded, and one teacher’s recent blog reported that a folder of handout materials typ­ ically is filed away and never used. Generally, it is better to have a few specific resources than overwhelming the audi­ ence with too many. Review videos in advance and have them set to begin exactly where needed to illustrate a point. If using

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PowerPoint, or similar platform, embed videos into the slides for more seamless viewing. Keep video segments brief and provide the audience with oral or written instructions concerning what they should look for during each segment. A number of videos and PowerPoint presentations are available online that can be accessed free or at minimal cost (see Suggested Readings and Resources at the end of this chapter; Chap­ter 7, Classroom Acoustics and Other Learning Environment Considerations; and Chapter 8, Hearing Instruments and Remote Microphone Technology). It is difficult to keep visuals updated with current technology, but often manufacturers will provide new graphics that could be easily inserted to update an earlier presentation when necessary. Visuals should be easy to read and have minimal information contained on each one. If the information on a slide is crucial, consider providing it in a handout as well. The same teacher’s blog mentioned previously stated, “Do NOT read PowerPoint slides to us!” Avoid using slides as speaker’s notes; blacken or use a blank slide, an interesting photograph, or related image for discussion time. Use images other than text on your slides to make a point (e.g., photos, charts, videos, graphics). Remember that you and your information are the focus, not the visuals. Standard guidelines for designing PowerPoint slides are summarized in Table 13–3. A list of currently available commercial materials useful for inservice presentations is included in Appendix 13–B. Commercial vendors are typically very eager to share research and materials that support their equipment, and they often will provide demonstration equipment on loan. However, it should be reemphasized that inservice for school personnel should be personalized as much as possible to the relevant educational environment, as illustrated by the students presently enrolled and the remote microphone hear-

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Use no more than eight lines of text. Use a common font that is easy to read. Use 20- to 28-point font for text. Use 28- to 44-point font for title text. Use a maximum of two fonts on a slide. Use high color contrast for readability. Be aware of color combinations that cause eye fatigue or those that can be affected by color blindness (e.g., avoid using red and green together). Design colors and contrast with the worst lighting situation in mind. Avoid using more than two text slides in a row. Include graphics as well as text. Graphics should relate to the topic. Avoid distracting visual effects (e.g., rapid appearance or disappearance of text).

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ing assistance technology (RM HAT) equipment in use or proposed for use within the participating school system(s). Commercial materials and older equipment should only be used to introduce topics or illustrate specific points. Often videos can be found online that support your presentation focus.

Preparing Technology and Facilities Technology  Immediately preceding the inservice session, make sure any audiovisual technology and demonstration equipment is working and positioned for easy access with appropriate space and lighting for interpreters, if used. A vari­ ety of media can help maintain attention during an inservice, but multiple pieces of equipment can lead to awkward body positions and occasional stumbles over extension cords if the equipment is not wireless. Use of a room public address (PA) system, if installed, or a portable classroom audio distribution system (CADS) with a pass-around microphone, should be used for all inservice sessions. This demonstration not only ensures communication access for all participants but also illustrates the use of the pass-around microphone. When personal hear­ ing instruments or hearing assistive technology (RM HAT) is to be demonstrated, equipment should be checked imme­diately before the session, and plans for troubleshooting should also be available just in case. Spare devices should be available for an inservice if audience members have not experienced their use before. (Equipment malfunction can be a great reinforcement for teachers whose RM systems always seem to break down just before the educational audiologist is scheduled to arrive.) A wireless mouse for use with PowerPoint or other computerassisted visuals allows the presenter to move about the room while talking or asking questions, but if this device has not been used before, the presenting educational audiologist should check its range and position for use. A Bluetooth portable speaker is another valuable tool to bring as some laptops and CADS may not be compatible with any audio/ visual clips that you plan to show. Finally, have a backup plan in case of equipment malfunction during the session. Valuable time can be lost while waiting for tech support, so use this time for activities such as informal discussion, brainstorming or group problem-solving, a review of audi­ ence questions, or even a rescheduled break. The Room  Structure the room so that participants can both see and hear; a U shape is preferred if numbers and space allow. Poor seating arrangements can dramatically illustrate difficulties faced by students who are deaf or hard of hearing, and time should be available for participants to change their seating arrangement(s) if that is the point being emphasized. Any time the audience is required to move around, a period of 10 to 15 minutes is required before they can come back together as a group.

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Presentation Dealing With Audience Effects Being sensitive and responsive to emotional states and practical needs of audience members can add to the enjoyment and effectiveness of an inservice session. Below are key strategies that can help to facilitate an environment conducive to adult learning. Personalize Information  Introduce yourself with a de­ scription that helps participants to identify with you and your experience (e.g., you have been a classroom teacher; your child has had ear infections; you are deaf or hard of hearing). Audience members listen and attend to presenters with whom they feel a personal connection. Reinforce the participants’ cur­rent knowledge and make information presented as spe­ cific to their situation as possible. The prevalence of reduced hear­ing is such that almost all par­ticipants will know some­ one (a child or an adult) who has a hearing problem. If it is possible to trigger thoughts of that person, any information provided immediately becomes more personalized and more likely to be remembered. If participants number fewer than 15 and their background is unfamiliar to the educational audiologist, ask each participant to make a comment that reflects on their interac­ tion with someone they have known or worked with in the past with hearing or listening challenges. Record this information on chart paper to incorporate in later discussion on incidence, demographics, challenges, and so on. This technique can be especially useful when participants do not know each other well, because they can immediately identify those with whom they share a common background.

TIP:  At the end of an hour-long inservice, have par­ ticipants write down two or three ideas on an in­ dex card that they would like to implement in the next week. Ask them to star one idea they could use within 24 hours.

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TIP:  Always have extra blank cards placed on tables or chairs around the room for questions that may arise during the inservice sessions. Some people feel more comfortable writing down their ques­ tions than asking them before the group.

Another familiarizing technique is to have participants take the first 2 or 3 minutes to write one question they have about the topic, on index cards that are provided when they arrive. Collect and review these cards during the first break to see if the information being presented is on target for this audience. Another strategy is to have participants answer relevant questions as a group during the wrap-up of the session, especially to emphasize key points addressed. Be Flexible  Allow time for questions throughout the pre­ sentation. Questions are invaluable for identifying issues of concern and the focus of audience members. Questions can let the presenter know if the information presented has been understood and when the information has already been personalized to individual participants’ teaching situations. If the answer is not known (or inaccessible during the stress of a formal presentation), arrange to follow up quickly with the participant at school. This, again, not only personalizes the information but is also a good marketing tool for the educational audiology program. Postpone questions if they will be more relevant during a later portion of the presentation, but remember to answer them and identify the person who asked, whenever possible. One technique that can be helpful for remembering questions is use of a chart or section of whiteboard for recording or “parking” deferred questions in full view of both the presenter and audience. Providing small pads of sticky notes to participants can facilitate this strategy; this is especially useful in preventing a discussion from going off on a tangent while still reinforcing that all questions are important to you.

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Teachers always appreciate a table for taking notes and spreading out, especially after a full day in the classroom. If there are extra materials to peruse, arrange them on a separate table for easy access. Check the temperature and the lighting and know where the controls are so each can be modified, if necessary, during the inservice. Many conference rooms and classrooms now have built-in media systems, and these can be very helpful if the presenter is familiar with the placement and use of controls for any available instructional technology.

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Be Alert to Physical and Mental Limits  Respect the par­ ticipants’ time and energy. No one likes to sit and listen for lengthy periods of time after a full school day. Let audience members specify or choose time for break(s); this strategy empowers attendees to allocate their attention in the way they believe is most productive. Encourage participants to move for better viewing or listening or just to change position

TIP: Change the pace. Listening with retention only lasts about 20 minutes at a time.

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when needed. This can be a meaningful demonstration of a recommendation for flexible seating often given for deaf and hard of hearing students. Consider placing bowls of candy or other food energizers on each table as well as sensory toys such as soft squishy balls that can also help the urge to fidget while listening.

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Use Ice Breakers and Humor  If the inservice is scheduled for a half or full day, consider taking time for a warm-up activity. One that has been used frequently is to break up into pairs or small groups and have each person introduce another participant, giving name plus one piece of personal information—hobby, children’s ages, pets, or travel fantasy. If your audience is large with participants sitting at tables, the introductions may be just among each table’s group. Small groups can be used to generate discussion, specific questions, or other concerns about hearing brought to the session. Familiarity among participants typically increases the comfort level of the audience, and knowledge of participant interest and motivations can be invaluable for the presenter. Humor can have many benefits during inservice, as well as life. Humor can reduce stress, facilitate learning, enhance creativity, diffuse anger and feelings of frustration, and improve communication. Strategic use of cartoons can illustrate key points, as well as serve as a break from processing auditory and written information. Daily comic strips often deal with pertinent points (e.g. competing noise, multiple word meanings, idioms), and these can be laminated and passed around during a presentation. Visual images are abundant online, but remember that including any copyrighted work on a handout requires permission from the author or publisher. Cartoons and jokes should be used judiciously, however, because they can become a distraction when there are too many or if they are not relevant to the topic.

Audiology or Amplification Equipment Demonstration If equipment is demonstrated, make sure all participants have hands-on experience before they leave the inservice. For example, the easiest way to demonstrate a classroom audio distribution system (CADS) is to use it when presenting. This technique is especially effective at the end of a school day, when everyone appreciates improved signal-tonoise conditions. Passing around a personal hearing instrument and a frequency modulated (FM)/digitally modulated

TIP: Personalized information is more easily re­ tained, and flexible seating for attendees reinforces recommendations often given for students with hearing or listening issues.

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Nuggets from the Field Provide earplugs for teachers to wear during lunch and ask them to jot down their impressions.

(DM) receiver on separate stethoscopes can be a dramatic demonstration of the difference in the auditory signal available to the student. Some educational audiologists have reported successfully using earplugs during this activity to demonstrate the possible effects of a mild hearing loss in one or both ears. Recorded simulations are another technique to illustrate the potential impact of various hearing levels and configurations in a variety of communication situations, and a number of these recordings can be incorporated into a presenter’s computer network. A list of sources for hearing loss simulations is provided in Appendix 13–B. To illustrate the benefit of visual supports in the classroom, use captioned videos whenever possible. If not specifically included in the formal presentation time, have a captioned video available for viewing during a break or demonstrate how to find captioned videos on YouTube. Participants typically are eager to have their own hearing screened using audiometry, tympanometry, or otoacoustic emissions if they have not done so previously, and these activities are easily completed during break times. Demonstrations for different apps for tablets, computers, and phones could be loaded and ready for presentation. One example would be ClearCaptions (https://clearcaptions.com), an app that transcribes voice phone calls to print. Another classroom app that could be demonstrated is Too Noisy Pro (apps.apple .com), a classroom noise level app that can help students and teachers regulate classroom noise levels. Again, as with lecture information, take every opportunity to incorporate practical applications into equipment demonstrations.

Use of Handouts Handouts can be used as outlines to follow during a presentation, for notetaking, or as follow-up information. Either use requires at least a mention and may need some direction during an inservice—for example, under what circumstances the handout might be useful or highlights for specific information on a reference list. Handouts should be easy to read and use (double or triple spaced, bulleted, highlighted by different fonts). If the inservice covers several different areas (e.g., RM HAT use and maintenance, teaching strategies, referral procedures), consider color coding handouts for easy future reference for participants. Appendix 13–C includes sample tips for teachers and equipment available for check-out that could be posted on index cards to leave with teachers after an inservice or follow-up coaching visit.

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Follow-Up Follow-up activities make up a critical part of any inservice program designed and delivered by the educational audiologist. Evaluation of materials and formal presentations helps to ensure that future inservice programs are informative and current. Participants should have the opportunity to evaluate the inservice at its conclusion either on a brief form or with a follow-up e-mail linked to a brief electronic survey. Most individuals do not return a form later if they take it with them. If a specific form is not already required for use in the school district, the educational audiologist should design one that will elicit the maximum information in a format that is quickly completed. If the educational audiology session was a part of a larger course or inservice program, provide evaluation questions that relate to the audiology portion of the course evaluation. A sample inservice evaluation form is included in Appendix 13–D. Review and reflect on the outline and objectives developed during the preparation phase. Were the objectives appropriate for this audience? Were the anticipated times

Nuggets from the Field Have teachers write down their e-mails before they leave. Follow up within a few days after the inservice with a quick summary of the presenta­ tion.This gives teachers a direct way to reply when they have questions.

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TIP: Demonstrate benefit from technology by us­ ing a classroom audio distribution system (CADS), including pass-around mic, to improve the signalto-noise ratio for your inservice participants.

realistic? Which activities were successful, and which ones did not go well? Why? What should be changed for future presentations? Reevaluate all handouts before disseminating them again. Were they read? Were they useful to and used by the participants after the inservice? Is the content still current? The reevaluation can take the form of a brief follow-up questionnaire for inservice participants or can be as informal as a glance around the teachers’ rooms the next day to see what happened to the materials that were distributed. In addition to observing which handouts seem to be used most often by inservice participants, educational audiologists should request selected teacher critiques of handouts before using them in the future. Log any follow-up contacts from partic­ ipants requesting additional information, materials, or educational audiology services. If handouts contain necessary information for attendees but were not read or used, try to rephrase or illustrate the point in a more meaningful manner for the next inservice.

Continuing Contact With Participants

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Gallaudet University’s InfoToGo program has developed a series of bookmarks with brief information about strategies for teachers to incorporate in their classrooms (see Suggested Resources at the end of this chapter). Always provide a single handout restating the critical points to be taken away from the inservice and include your contact information (e.g., name, office address, phone/text number, e-mail, and hours you can typically be reached). If office hours are not an option, make sure you provide the best way you can be reached. Information on slides should be considered as handouts. A preferred “greener” strategy for providing copies of a PowerPoint presentation is to send it on request via e-mail. Permission should be obtained for copyrighted material before dissemination and sources should be credited on each relevant page. Commercial brochures and other written materials may contain useful information, but they are frequently not personalized and too general for immediate use. Although they typically have an eye-catching design, they are more likely to be placed on a shelf or in a file without being read.

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Follow-up contact with educational team members (see coaching section later in this chapter) helps to ensure that information is retained and implemented for the benefit of the student(s) being served. Provide a sign-up list for participants during the initial inservice presentation. Sending a follow-up message or letter through the school’s communication network identifying activities that can be requested is another way to elicit opportunities to interact individually with inservice participants after a formal presentation. Include a request form and referral sheet with these messages. If specialized equipment such as video phones, captioning, or a classroom audio distribution system is available for loan, provide a sign-up sheet for such equipment and other materials identified during the inservice. Even if directions for installation and use are not required, another opportunity for face-to-face interaction can occur if the educational audiologist delivers the requested equipment or material in person. It is critical to provide follow-up information on specific students in small group or individual conferences to ensure that relevant information has been understood and that recommendations are being implemented appropriately. Use of small group sessions as a follow-up to an educational audiology inservice is an efficient way to help school

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TEAMING IS: Guiding, not directing Collaborating, not competing Guidelines, not rules Activities, not lectures Diversity, not sameness Openness, not secrecy Active not passive Involved, not isolated Adapted by K.Yuskow from Use of   Teams in Classes

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personnel implement information on troubleshooting of personal hearing instruments and RM HAT. The EARS program in Arkansas has developed a series of very short YouTube videos demonstrating several amplification systems, maintenance, and troubleshooting tips (https://www.youtube.com /playlist?list=PLStceB-WlntRlSi7FXtKloLGlVUDtieKW). If a student has a similar device, these could be shown in a small group or individual follow-up session as a support for written and/or more formal inservice information. Collaborative follow-up for the student’s educational team might include the regular classroom teachers, specialized instructional support personnel, tutors, interpreters, speechlanguage pathologists, building administrators, other adults involved in extracurricular activities, and the students themselves. Staff and student responsibilities could be assigned during this session, and a workable form for daily recording for equipment function could be developed or modified at this time. Whenever possible, allow students to identify and assume their own responsibilities for troubleshooting their personal hearing instruments and HATs. (See Chapters 9 and 10 for more information on self-determination and selfadvocacy for deaf and hard of hearing students.) Classroom Observations and Individual Con­sul­ta­tions  Chapter 2, Roles and Responsibilities of Educational Au­di­ ologists, and Chapter 9, Case Management and Habilitation, discuss the roles of educational audiologists in case man­agement and consultation. This information serves to illus­trate the importance of proficiency and flexibility when delivering information for maximum benefit of individual students with hearing or listening difficulties. It is imperative that teacher requests for consultation for students with reduced hearing be addressed by the educational audiologist as quickly as possible, even if the information requested has been given previously in writing or during an earlier face-to-face contact. Teachers may request a classroom observation as a follow-up to an inservice. The request may be for a student

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exhibiting hearing or listening problems not yet formally identified or, more likely, regarding assistance for a student already identified and receiving support on an IEP or 504 plan. Requests should be followed up quickly to reinforce individual interactions with teachers that can facilitate continued consultation in the future as well as promote appropriate intervention for the student. If the concerns are regarding a new student, the observation can introduce and guide interventions through the school’s response to intervention (RtI) or Multi-Tiered Systems of Support (MTSS) process or result in a potential referral for special education services. Special Activities on Request  Additional requests subse­ quent to an educational audiology inservice may include measurement of classroom noise levels, lecture or classroom teaching covering anatomy of the ear or the hearing process, information for a spouse or other relative concerning hearing assessment and amplification, or student/staff information on ear protection. Although some of these activities may not be listed as a priority in the educational audiologist’s job description, each affords an opportunity to build credibility and improve communication with local school staff members. For this reason, whenever a request follows an inservice, it should be addressed by the educational audiologist as quickly as possible.

COACHING AND MENTORING Coaching is a trainer/trainee strategy being utilized in many aspects of business, educational, and professional communities. Coaching is defined broadly as a form of development in which a person called a coach supports a learner or client in achieving a specific personal or professional goal by providing training and guidance. There are many different types of coaches depending on a person’s needs (e.g., life coaches, fitness coaches, leadership coaches, career coaches), as well as numerous models of coaching in both business and education. Regardless of the enterprise, each coaching model incorporates building relationships, using effective communication, supporting personal and professional goals, and incorporating reflection. Mentoring, like coaching, is also a relationship-based professional support model where a more knowledgeable and experienced individual advises and supports an individual with less knowledge and experience in the same or similar profession. The overall goal for mentoring, like coaching, is to promote and support the independent decision-making and practice of the individual being mentored or coached.

Educational Coaching Education has implemented a focus on coaching practices to improve student and school outcomes. Districts are utiliz-

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Supporting the Educational Team TABLE 13–4  Open-Ended Questions and Comments for Coaching Conversations ■■

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Coaching for Educational Audiologists Educational audiologists are charged with providing teams of educators with training and guidance as defined by our role. IDEA 20041 requires the training or technical assistance for professionals (including individuals providing education or rehabilitation services), employers, or other individuals who provide services to, employ, or are otherwise substantially involved in the major life functions of children with disabilities. In addition, the Educational Audiology Association’s (EAA) recommended professional practices for educational audiologists include provision of inservice training and consultation to school personnel, parents, and students regarding impact of hearing loss as well as training for HAT (EAA, 2009). A common theme that has emerged from the coaching literature incorporates adult learning and action. Elena Aguilar (2013) identifies three questions to think about when preparing for a coaching conversation: 1. How can I make this conversation meaningful to the teacher? 2. What’s one question I can ask the teacher to help them reflect on their practice? 3. What’s one instructional practice that might be useful for this teacher to reflect on and make a change in? How can I help this teacher reflect on this behavior and make changes?

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Tell me about a time that you worked with a student who has hearing loss. What changes do you think your student would really appreciate? What possibilities do you see for yourself in the next few weeks/months? What would it take to succeed with __________________? How would you rate your confidence in implementing ___________? What do you think are the best possible outcomes of our work together? How can you expand this experience for even better results next time?

Applying coaching models to educational audiology services can motivate teachers and other support staff to implement strategies for deaf and hard of hearing students in a more consistent and successful pattern. Questions such as those listed in Table 13–4 can foster relationship-based conversations with educational team members. It is important that we build trust with the teachers and staff in our schools. This is a process that takes time, but the student outcomes are generally positive. Many audiologists report that they are covering large territories and do not have time to build relationships. This is where thinking outside of the box for coaching is important. Can you send a weekly email? Can you do a teleconference to check in? Can you do a monthly check in? A second main theme that has surfaced from the coaching model practice is listening. Many times our inservice sessions attempt to provide all the information we want teachers to know related to hearing and communication access in 30 minutes. Then we leave them with a handout, and

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ing educational coaches to assist administrators and teachers to incorporate effective practices that will help them attain their goals. This process differs from traditional evaluations as schools increasingly are looking to coaching and other relationship-based professional development strategies to improve the skill and performance of teachers and school leaders. Such interventions lead to improved school climates and teachers who are productively engaged in the work of student learning (Tschannen-Moran, 2011).

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Nuggets from the Field “There are times when I think my message has been loud and clear about the needs of a student with hearing loss in the classroom. A follow-up visit tells me something different when the teacher lets me know that they have not been wearing the transmitter because the student seems to be hearing fine without it.”

Nuggets from the Field “I have learned that chocolate goes a long way! I often carry some with me to support teachers’ good microphone use, placement, etc. While most times it works like a charm, there was that instance when a teacher on a diet was offended . . . oops!!”

1

 34CFR303.13(b)(1)(i)(f).

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Good coaches respect teacher awareness, choice, and responsibility.They understand teacher experi­ ences and show empathy and appreciation. They recognize vitality and build on teacher strengths. Tschannen-Moran (2011).

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off we go to conduct the next scheduled inservice. What if we started the session with a question for the team that gave us the opportunity to listen to their concerns? “What are you most looking forward to learning about having a deaf or hard of hearing student in your classroom or school?” “What is one thing that you are wondering about?” Then, carefully listen to what each person has to say, ask clarifying questions, and provide relevant information and reflective feedback to generate meaningful discussion targeting student needs. A third theme that surfaces from coaching practice is supporting the right work. At the end of the inservice, what if we asked the team, “what is one practice that you want to focus on in the next week?” Our next step is then to help each teacher set up a specific goal for himself or herself. Finally, it is our job to follow up and follow through. The coaching model can be utilized in each of our follow-up con­ versations whether on the phone, through e-mail, teleconference, or in person. (See Appendix 13–E for an example of combining a coaching approach with a formal inservice session.)

Mentoring Mentoring is similar in concept to coaching, and some even consider these terms to be synonymous. Historically, the U.S. Department of Education (1993) described mentoring

SUMMARY Inservice for district staff and ongoing team member consultation need to be integral parts of an educational audiology program. Too often, students with hearing challenges remain unidentified or underserved because school personnel are not given information in an interesting and relatable format, and too often we feel that time for developing supportive coaching relationships is not available. Successful adult learning requires active engagement and regular systematic feedback. Educational audiologists should develop ongoing lists of successful techniques used in both group and one-on-one meetings and adapt these whenever possible for use in a school-based inservice. Information on successful techniques and relevant materials can be shared during

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as a relationship between adults and youth, and for more information on this perspective for educational audiologists and deaf and hard of hearing students, see Chapter 10, Supporting Wellness and Social-Emotional Competence. If you are a new educational audiologist working for the schools, consider reaching out to an experienced educational audiologist to be a mentor. If you have one in your district, ask to schedule monthly meetings to connect and ask questions. If you do not have another audiologist in your district, reach out to your state department of education or the EAA for potential educational audiology mentors. Mentoring does not have to take place in person and could be arranged through video teleconferencing if distance is an issue. For educational audiologists working with new educational audiology staff and/or related team members, the knowledge, advice, and resources shared as a mentor depend on the format and goals of the specific mentoring relationship. In these situations, information to be shared between mentor and mentee may include personal career path details, as well as guidance, motivation, emotional support, and role modeling. Support and assistance may also be provided for exploring professional development, setting goals, developing contacts, networking, and identifying resources. In these relationships, characteristics of mentoring are similar to those of coaching and include: ■■ ■■ ■■ ■■

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valuing the mentee as a person; developing mutual trust and respect; maintaining confidentiality; listening to how things are said as well as what is being said; helping mentees to solve their own problems, rather than giving direction; and focusing on the mentee’s individual development and resisting the urge to produce a clone (University of Washington, 2019).

peer group meetings and mentoring relationships, as well as through professional newsletters and conferences. Thoughtful planning and rapid follow-up can help to improve skills and expand opportunities for inservice, coaching, and mentoring for educational audiologists.

SUGGESTED READINGS AND RESOURCES Gallaudet University, Laurent Clerc National Deaf Education Center. (2015). Tips to Go, Accommodating deaf and hard of hearing students in schools. Retrieved from https://www3.gallaudet .edu/clerc-center/tips-to-go.html

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Severance, G., & Klein, B. (2012). What you need to know about student’s hearing technology for classroom listening. PowerPoint and handout. Retrieved from https://successforkidswith hearingloss.com/ Success for Children with Hearing Loss. (2019). Inservicing the classroom teacher. Retrieved from https://successforkidswith hearingloss.com/inservicing-the-classroom-teacher Tschannen-Moran, B. A. (2010). Evocative coaching: Transforming schools one conversation at a time. San Francisco, CA: Jossey-Bass. University of Washington, Northwest Center for Public Health Practice. (2014). Effective adult learning: A toolkit for teaching adults. Retrieved from http://www.nwcphp.org What is coaching? Retrieved from https://www.skillsyouneed.com /learn/coaching.html

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Kee, K. A. (2010). Powerful communication skills: The new essentials in results coaching: The new essential for school leaders. London, UK: Sage Books. Naeve-Velguth, S., Hariprasad, D., & Lehman, J. (2003). A comparison of lecture and problem-based instructional formats for FM inservice. Journal of Educational Audiology, 11, 5–14. Peterson, D. (2019). The basics of adult learning. ThoughtCo., March 6. Retrieved from https://www.thoughtco.com/what-is -adult-learning-31425 Pike, B., & Solem, L. (2013). 50 Creative Training Openers and Energizers: Innovative ways to start your training with a Bang! Hoboken, NJ: Wiley. Pike, R. (2002). Creative training techniques handbook (3rd ed.). Amherst, MA: HRD Press. e-book (2003).

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APPENDIX

13–A Inservice Outlines

TIPS FOR USING OUTLINES: ■■ ■■ ■■

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Copy on 5 × 8 index cards. Start a new index card for each segment. Write down stopping points for each video or audio segment. Set at next beginning point immediately after playing segment. Color code supplementary materials (handouts, slides video, equipment) and insert in sequence of use. Write out important points to emphasize for each segment.

TITLE: GETTING STARTED (30 MINUTES) TARGET AUDIENCE: TEACHERS AND SCHOOL PERSONNEL WHO HAVE A STUDENT WITH IDENTIFIED HEARING OR LISTENING NEEDS Rationale: Teachers and school personnel have many requirements and trainings at the start of the school year. In order to ensure that a deaf or hard of hearing student has a good start to the school year, it is important that teachers have foundational information regarding the impact of hearing challenges in the classroom. Below is a starting outline of components that you may want to include. If you are running out of time during the scheduled inservice session, think about what three KEY points you want EVERY teacher to remember. The educational audiologist should plan a follow-up visit with the core teacher and/ or primary contact staff member within 2 weeks if at all possible. Chapter 13

OBJECTIVES: Participants will gain an overview of hearing and different hearing levels Participants will gain an overview of a particular student and his/her needs ■■ Participants will demonstrate competency in the student’s personal equipment as well as remote microphone technology ■■ Participants will identify individual accommodations outlined in the student’s IEP/504 plan and be able to explain why they are needed. ■■ Participants will identify who to contact when he/she has questions or concerns. Initial Activity: 3 minutes ■■ Participants will sign in with their name, room number, and e-mail address (or best way to be contacted) ■■ Participants will introduce themselves and explain how they will be serving the student ■■ Participants will briefly share prior experience with hearing loss (could be yes/no, student/family member/other, cause, treatment, etc.] ■■ Participants will share (verbally or by writing down on index card) one thing they are most looking forward to learning about regarding hearing and listening challenges. Overview of Hearing and Student’s Hearing Loss: 7 Minutes ■■ Briefly discuss how critical hearing is for classroom learning. Discuss briefly that hearing levels are measured on a continuum and can range from mild to profound, unilateral or bilateral, fluctuating and/or permanent. Any degree of compromised hearing can have a negative impact on how a child communicates, learns, and his/her access to information. Some related factors (not exhaustive) may include motivation, history of hearing loss, type of hearing loss, language level, use of technology, and environment. ■■ Have participants take the unfair spelling test (can use the mild hearing loss word list in order to save time). This is available on YouTube and other hearing loss websites (e.g., https://successforkidswithhearingloss.com ) Mention the issue of fatigue when a student has to work so hard to understand information in the classroom. ■■ Share specific information about the specific student’s hearing. ■■ Ask participants what they might expect from info they have been given about hearing loss. Then repeat info that each student is an individual and might be totally different than they expect. Emphasize that the accommodations that have been recommended are individualized to help each student have the same access to information as his/her classmates. ■■ ■■

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Demonstration of Personal Hearing Technology and Hearing Assistive Technology: 10 Minutes Participants will learn about the student’s specific technology that is being used. If loaner equipment or the student’s technology is available, participants can listen to the devices. If not available, use an audio recording or YouTube video of what hearing aid, cochlear implant, and RM HAT sounds like (see online resources). Supplementary Materials:

■■ ■■

■■ ■■

Student’s technology for demonstration and troubleshooting Teacher sheets for use and troubleshooting of student’s equipment (see Chap­ter 8 for examples) Calendar or Ling Six-Sound Chart (Appendix 8–I) for daily monitoring Troubleshooting kit (battery tester, air blower, dry aid kit, extra batteries)

Classroom Accommodations for Student: 5 minutes Review typical barriers to listening in the classroom (noise, distance, reverberation, external and internal noise sources). Reflect back on the unfair spelling test and how difficult and tiring it was to hear and understand the given words. Technology can help, but it is not a cure. Ask participants to quickly brainstorm potential accommodations. Then, as a team, review the student’s current Individualized Education Program (IEP)/504 accommodations and expand on why these accommodations benefit the student. Supplementary Materials:

■■ ■■

Summary sheet specific for the student listing technology and accommodations Student created “All about Me” handout. This could be a self-advocacy/learning activity that is done each school year and shared by the student with his/her team.

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Summary: 5 minutes ■■ Quickly summarize the above components. What are your three KEY points that you want the team to implement right away? ■■ Schedule a classroom visit ASAP to review technology and accommodations and answer any questions that will surface. ■■ Leave your business card with best ways to contact you.

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TITLE: CLASSROOM AMPLIFICATION (45 MINUTES) TARGET AUDIENCE: ADMINISTRATORS OBJECTIVES: Participants will gain knowledge about classroom amplification. Participants will experience classroom amplification. ■■ Participants will receive information concerning benefits of using classroom amplification in educational settings. Initial activity (3–5 minutes): Participants and instructor introduce themselves while a tape of classroom noise is being played; show slide and turn off noise. Reactions? ■■ ■■

Materials needed:

Audio recording made in local classroom  Slide photo of classroom with students

I. System Overview (15 minutes): Turn on classroom FM system and identify microphone and speakers being used; explain equipment, advantages, and other system options (alternate microphone styles and speaker arrangements) following ICA transparencies Materials needed:

Working classroom FM system YouTube videos from Jane Madell, EARS project, or similar (see resources)

II. Benefits (15 minutes): Summarize research demonstrating benefit from sound-field amplification (MARRS study); identify at-risk populations with local statistics for each category. Materials needed:

ICA slide IV-8, “Summary of FM Soundfield Benefits Based on Research Findings” Handout—annotated research studies on classroom amplification Handout with local info for each category

III. Summary (10 minutes): Present classroom info for initial audio demo using classroom grid from ICA manual); proposal for trial period in local classrooms; questions and answers Chapter 13

Materials needed:

Classroom audio demo Transparency/slide of classroom noise measurements Commercial packets

Activity: Replay classroom audio while using classroom FM system and explaining grid Activity: Pass out commercial package on equipment proposed for trial that includes estimated costs if purchased; schedule follow-up appointments to select classrooms and develop plan for training and data collection

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TITLE: HEARING AID MONITORING (1 HOUR) TARGET AUDIENCE: SUPPORT PERSONNEL OBJECTIVES:

Participants will accurately identify parts of behind-the-ear (BTE) and in-the-ear (ITE) hearing aids. Participants will demonstrate competency in routine visual and listening checks for BTE and ITE hearing aids. ■■ Participants will demonstrate knowledge of solutions for typical hearing aid malfunctions. Initial activity: Pre-test (5 minutes): Fill in the blank illustration of BTE and ITE hearing aids I. Review parts of aids, using loaner BTE and ITE hearing aids (10 minutes): battery, on–off switch, volume control, microphone, tone/output controls, amplifier, tone hook, tubing, earmold. Identify make, model, and serial number for each aid used. Distribute battery warning and demonstrate childproof battery compartment. Group asked to ID parts on slide or handout. ■■ ■■

Materials needed:

BTE and ITE hearing aids—no less than one for every two participants Handout/PowerPoint slide of Pre-test

II. Visual inspection and possible problems (20 minutes): Case, battery compartment, OTM switch, tone control, tubing, earmold; basic cleaning instructions; moisture problems and solutions Materials needed:

Handout listing visual inspection components. Hearing aids with hole in tubing, scratched/dirty case, cerumen in earmold, loose/broken tone hook, missing battery door/tone control cover Cleaning “supplies,” air blower Dri-aid kit and instructions

Materials needed:

Handout listing problems and troubleshooting techniques Hearing aid stethoscopes Battery testers Hearing aids with battery upside down/dead; dead aid; aids with internal feedback, distortion, static Brief video clip to summarize (ck. Mfg. resources)

IV. Summary (5 minutes): Procedure for reporting problems that cannot be solved during daily check; post-test (connect problems and troubleshooting technique); questions and answers.

Chapter 13

III. Listen check and possible problems (20 minutes): feedback; Ling sound check using stethoscope.

Note: Schedule follow-up classroom visit ASAP for any support personnel who are responsible for daily monitoring of hearing aids.

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APPENDIX

13–B Inservice and Hearing Simulation Resources*

A.G. Bell Association for the Deaf, Inc. 3417 Volta Place, NW Washington, DC 20007-2778 https://www.agbell.org Free downloadable handouts for mainstream teachers KIP-Knowledge Is Power Audiological and Education Distributed by Educational Audiology Association 3030 W. 81st Street Westminster, CO 80031-4111 800-460-7322 http://edaud.org Program designed to help students learn about their hearing losses

Chapter 13

The Mainstream Center Clarke Schools for Hearing and Speech Round Hill Road Northampton, MA 01060-2199 413-582-1121 (V/TDD) http://www.clarkeschools.org/services [email protected] Link to mainstream services including downloadable information and videos for teachers, educational products and conferences, and subscription information for The Mainstream News, periodical for school personnel published five times per year. Videos, DVDs, and print materials on oral transliterating. Phonak, Inc. 4520 Weaver Parkway Warrenville, IL 60555 800-777-7316 Information and multiple links to resources for pediatric hearing loss and APD; information and demonstrations on noise, FM, and classroom amplification National Information Center on Deafness, Gallaudet University NICD, Dept. P-94 800 Florida Avenue NE Washington, DC 20002 (202) 651-5000 (V/TDD) https://www3.gallaudet.edu/clerc-center/info-to-go.html Manages Educational Resource Centers on Deafness; catalog in­cludes current mainstream modules, videos, publications

Supporting Success for Children with Hearing Loss https://suc cessforkidswithhearingloss.com/product/teacher-inservice -combo/ Includes five checklists and 12 handouts helpful for inservicing.

Additional Web Resources and Hearing Loss Simulation Sites Tina Childress’ site

https://www.youtube.com/watch?v=RBrnvGKLF_Q Short (5-min) video created by pediatric audiologist, Jane Madell, that demonstrates difference between classroom listening with and without FM support. https://successforkidswithhearingloss.com/for-professionals /demonstrations-simulated-listening-with-hearing-loss-de vices/ (2016). Website with collection of a number of simu­ lations of differing conditions for hearing (e.g., quiet, noisy, various levels and etiologies of hearing conditions). References and sources are identified for many of the simulations. https://www.bced.gov.bc.ca/specialed/hearimpair/toc.htm Hard of hearing and deaf students: A downloadable resource guide to support classroom teachers. (2007). British Columbia Ministry of Education. http://www.deafed.net Online information and resources for teachers of students who are deaf/hard of hearing. Brings up page with links to Hands and Voices materials for deaf/hard of hearing students, families, and providers. http://www.handsandvoices.org/ Website developed and maintained by nonprofit, parent-driven organization dedicated to supporting families of children who are deaf or hard of hearing. Articles and useful links to information and resources for families and professionals on communication options, deaf education, legislations, and other topics of interest. https://www.utdallas.edu/hhlab/resources-and-publications /tutorials-on-wireless-technology/ PDF and PowerPoint tutorials developed by Linda Thibidoux, PhD, at UTDallas Hearing Health Lab that illustrate FM technology, coping strategies for teens, and transition from high school. http://www.oticonus.com/css/Ecaps/Pediatrics%20Counsel ing.zip Large (130 MB) download included in the Pediatric

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Counseling Program developed by Oticon Corp. Can also be requested on a free CD from http://www.oticonus.com https://www.phonak.com/au/en/hearing-loss/signs-of-hear ing-loss-and-what-to-do/hearing-loss-simulation.html Simulations developed by Phonak of different levels of hearing loss listening to singing, conversations, environmental sounds, recorded pop music, etc.

Additional sites with hearing loss simulations:

■■

Simulations (http://www.healthsciences.uci.edu/). Acous­ tic simulations of cochlear implants and auditory neuropathy YouTube demos using Fred Flintstone character (http:// www.youtube.com/watch?v=1EJ4g3J6cJM&feature =related)

*Readers’ note: URLs and websites change frequently, so we apologize for any of these sites that are no longer available. Please share this information with your colleagues and help us to keep our online section as up to date as possible. Thank you.

YouTube: Name that sound—What does hearing loss sound like? (http://www.hearingcenteronline.com/sound .shtml)

Chapter 13

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APPENDIX

13–C Sample Index Card Handouts Tips for the Classroom

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■■ ■■ ■■ ■■ ■■

Maintain the same high expectations for deaf and hard of hearing students as you have for their hearing peers. Take time to learn about each student’s family and background. Learn what works in communicating effectively with each student (e.g., being close to the student, speaking clearly, showing your face to the student when speaking, lighting, amplification). Create visual supports such as graphics, charts, hands-on demonstrations, and PowerPoint presentations. Allow time to view pictures and/or read information. Repeat and paraphrase information to ensure clarity. Identify who is speaking during class discussions. Create accessible materials as appropriate for students’ skill levels as indicated on their Individualized Education Programs. Source: Gallaudet University, Laurent Clerc National Deaf Education Center (2015).

Chapter 13

EQUIPMENT AVAILABLE FOR STUDENTS AND TEACHERS IN DISTRICT The following equipment is available for short- or long-term loan for use in district classrooms: ■■ ■■ ■■ ■■ ■■ ■■ ■■

Classroom amplification system (CADS) Personal RM/FM units TV caption adaptor Amplified telephone training unit Sound level meter 3-D model of the ear Sample earplugs

Contact, Educational Audiologist, at for details.

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APPENDIX

13–D Inservice Evaluation Form

  1.  Inservice content was appropriate for my needs

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  3.  Presentations were interesting

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  4.  Presentations were informative

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  5.  Presenter was knowledgeable about topic

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  6.  I acquired relevant information during this inservice

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  7.  I obtained materials/resources that I can apply in my work situation

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  8.  I would recommend that my colleagues attend this inservice if it were presented again

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INSERVICE  TITLE: DATE: Please mark 1 to 5, with 1 = Strongly Agree to 5 = Strongly Disagree

  9.  What I liked best about this inservice:

10.  What I liked least about this inservice:

11. Suggestions for improving this inservice in the future:

12. Name and contact information (optional):

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APPENDIX

13–E Sample Coaching Concept Organizer

Serving a deaf or hard of hearing student extends past the initial teacher/staff inservice. Applying coaching models to educational audiology services can motivate teachers and other support staff to implement strategies for deaf and hard of hearing students in a more consistent and successful pattern. It is important that we build trust with the teachers and staff in our schools. Following is a sample outline on how to continue to support and coach a mem­ ber of the student’s team after the inservice.

Logistical Preparation ■■ ■■

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Identify a key teacher/professional after the inservice Identify a time together that works for both of you for follow-up meeting Together designate a specific amount of time to meet (30 min) Have a variety of ways to meet (in person, through teleconference, on phone); identify teacher/professional’s preferences

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Coaching Mindset Questions

These questions will help you frame your mind before meeting with the teacher to ensure that this is beneficial for the teacher. 1. How can I make this conversation meaningful to the teacher? 2. What is one question I can ask the teacher to help them reflect on their practice? 3. What’s one instructional practice that might be useful for this teacher to reflect on and make a change in? How can I help this teacher reflect on this behavior and make changes?

Initiate coaching engagement with listening …… What are you most looking forward to learning about ­­­­_____________ (hearing loss, student)? …… What is one thing that you are wondering about? Validate engagement responses …… Offer reflection …… Celebrate progress Inquire and expand on what the teacher would like to learn or problem-solve …… Personalize learning goals …… Hands-on opportunities …… Handouts to reference …… Summarize with two or three key points Conclude coaching with action items …… What is one thing you learned today? …… What is one practice that you want to focus on? …… How can I help you? …… What suggestions do you have for me? Follow-up to build trust and communication …… Schedule a follow-up visit …… Send e-mails to check in …… Use teleconferencing to check in …… Personalize the follow-up by asking “How is ________(the teacher identified action) working in the classroom?”

Educational Audiology Reflection on Coaching ■■

Reflect on the coaching session …… What are two or three things that went well? …… How did you feel afterward? …… What are two or three things that did not go well? …… What could you do differently next time? …… When will you follow up to continue developing trust and communication with this team?

Coaching Meeting ■■

Establish Rapport: Ask how things are going? Ask about something that is personal to this teacher (Pet? Kids? Upcoming trip). What’s the best thing that’s happened to you this week?

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CHAPTER

14

Educational Considerations for Students Who Are Deaf or Hard of Hearing CONTENTS

Chapter 14

Critical Issues in Deaf Education Accountability and Oversight ■ Communication and Communication Access ■ Quality Instruction Evidenced-Based Practices ■ Students Not Eligible for Special Education ■ Maintaining Teacher of the Deaf and Related Service Provider Positions ■ Parent and Family Engagement ■ Early Hearing Detection and Intervention and Early Childhood Education ■ Technology ■ Deaf Versus Hard of Hearing

Captioned transcript of student describing communication challenges.

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CONTENTS 

(Continued )

National Association of State Directors of Special Education: Ten Essential Principles for Effective Education of Deaf and Hard of Hearing Students What Is Research Saying? Legislative Initiatives in Deaf Education Language Acquisition and Literacy Accountability ■ Deaf Child’s Bill of Rights ■ Hearing Aid Insurance Educational Assessment Transition Planning Best Practice Considerations for Educating Children and Youth Who Are Deaf or Hard of Hearing Know Your Students ■ Program Standards ■ Program Review ■ Evidence-Based and Consensus-Based Practices Progress Monitoring ■ Expanded Core Curricula ■ Deaf and Hard of Hearing Peers and Role Models ■ Engage Parents and Caregivers Summary Suggested Reading Appendices 14–A Colorado Individualized Education Program Communication Plan (Text/Online) 14–B Assessment Terminology (Text) 14–C Summary of Psychoeducational, Language, and Communication Assessments (Text) 14–D National Association of State Directors of Special Education (NASDSE) Implementation: Deaf and Hard of Hearing Program and Service Review Checklist (Text/Online)

KEY TERMS Chapter 14

Evidenced-based practices, progress monitoring, expanded core curriculum, transition, educational assessment, Universal Design for Learning, legislation, NASDSE

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While early identification and intervention have improved language outcomes for many young children, all remain at-risk for later learning problems and must be closely monitored. Many critical issues in the education of deaf and hard of hearing students continue to be barriers to successful outcomes. A variety of instructional strategies are needed to address individual language and communication approaches. Research is providing more evidenced-based strategies for improving outcomes. Professional guidance, such as provided in the National Association of State Directors of Special Education (NASDSE) Guidelines, can help school districts evaluate their deaf education services and plan program improvements.

The education of students who are deaf or hard of hearing is multifaceted and often poorly understood by educators and administrators. While the issues are complex, solutions exist, and there is evidence that the trends are reversing for many students. To do so, however, requires commitment to the goal that all deaf and hard of hearing students will achieve the same outcomes as their hearing counterparts and that our work is not done until that goal has been attained. Educational audiologists play an integral role in supporting the education of students with reduced hearing levels, as well as those who have normal hearing accompanied by listening and/or auditory processing difficulties. Though a primary role of educational audiologists is maximizing audition and ensuring communication access to facilitate learning in school and for social participation, we have a role with students’ overall educational programs as members of the educational team. To be an effective team member, we must be knowledgeable about the issues and practices associated with assessing and educating deaf and hard of hearing students and be prepared to advocate for the services they need. This chapter pertains primarily to students who are deaf or hard of hearing. Students with auditory processing deficits were addressed in previous chapters. Questions that will be addressed include the following:

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What are critical issues regarding the education of deaf and hard of hearing students? What is current research saying about outcomes for deaf and hard of hearing students? What is the status of state and national initiatives supporting deaf and hard of hearing children and youth? What are common assessment practices? What are best practices in the education of deaf and hard of hearing students?

CRITICAL ISSUES IN DEAF EDUCATION In 1975 the Individuals with Disabilities Education Act (IDEA) mandated that children with disabilities were entitled to be educated in the least restrictive environment (LRE), i.e.., the environment where their typical peers were educated. With the goal that children with disabilities were not to be isolated, inclusion has been the conceptual basis of an educational system designed to provide equal opportunity for all students, with or without disabilities. Over time, it has become clear that while inclusion has served many children with disabilities very well, that is not always the case for many children who are deaf or hard of hearing (DHH). Communicating “differently” or without direct conversation with teachers and peers can create the most restrictive environment for many DHH students in a classroom of hearing peers. Legally, “LRE” has been interpreted and implemented without sensitivity to, or acknowledgement for, the special communication needs presented by deaf children that often go unmet in the “least restrictive environment.” The outcome has been isolation and academic underachievement. Until the conceptual basis of education (and all supporting mandates) is understood to be communication-driven for DHH students, the system will continue to discriminate against this population. In fact, it is the inequity of our present educational system that has resulted in the further disabling of DHH children. At the federal level, the importance of communication as a starting point for identifying appropriate services

for a child was first acknowledged in “Deaf Students Education Services: Policy Guidance” 57 Fed. Reg. 49274 (1992). This report stated that “The (U.S. Department of Education) Secretary believes that communication and related service needs of many children who are deaf have not been adequately considered in the development of the IEP.” Moreover, it points out that the child’s communication needs, linguistics needs, and social and emotional needs must be primary factors in considering the least restrictive environment for each child. The general classroom does not adequately serve all DHH students because it frequently denies full communication access. As long as communication is perceived as secondary to the Individuals with Disabilities Education Act’s (IDEA) core concept of LRE, the specific and systematic problems that are unique to educating DHH children will continue. The intent of IDEA, is to decrease, not increase, a child’s isolation. (Colorado Department of Education, 2002, pp. 8–9).

Simply understanding the implications of fragmented hearing or not hearing, and particularly the resulting impact on communication, is one of the biggest challenges in deaf education. It becomes even more important when you consider the fact that most children with reduced hearing now receive the majority of their education in general education classrooms as illustrated in the comparison between 2007 and 2016 in Table 14–1. Accountability, as the hallmark of the No Child Left Behind (NCLB) Act, created the most significant force for instructional change in schools in many years. NCLB’s commitment to all students also provided an opportunity to focus on the access and performance of students who are deaf or hard of hearing and address some of the long-standing challenges. The Every Student Succeeds Act (ESSA), the current version of the Elementary and Secondary Education Act, signed into law on December 10, 2015, reduced many of the federal requirements of NCLB giving more discretion to states to determine academic standards and assessments, while continuing the focus on accountability.

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Accountability and Oversight The NCLB and ESSA focus on accountability has yielded systemic analysis of the performance of students who are

TABLE 14–1  Trends in Placement for Deaf or Hard of Hearing (DHH) Students 2007 Versus 2016.

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Office of Special Education Programs (OSEP) Annual Data Collection

Fall 2007

Fall 2016

DHH students in general educational class >80%

51.88%

61.30%

DHH students in general education class 40% to 79%:

17.64%

15.50%

DHH students in general education class 33% scored average to above average. Reading and writing, 50% to 60% scored in the average range. Over 5 years, on average, students made a year’s growth in 1 year in reading and math; writing more than 1 year’s growth. Teachers rated 70% to 80% of students’ achievement to be in the average to above average range in academic competence compared to classmates. Classroom participation—on average, students ranked themselves as “almost always” understanding their teachers and classmates. Social Skills and Problem Behaviors questionnaire completed annually (Social Skills Rating System, Gresham & Elliott, 1990). …… Social Skills: Over 5 years, on average, teachers rated 80% of students as average or above average; students rated themselves similarly. …… Problem Behaviors: Teachers rated