Setting Appropriate Expectations And Communication Goals .

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ProgramSetting AppropriateExpectations andCommunicationGoals with aCochlear ImplantNameTitle

MissionAt Advanced Bionics we are dedicated to improving lives bydeveloping technologies and services that help our recipientsachieve their full potential. Our commitment to putting patients first and providing thebest possible hearing performance remains at the forefrontof all that we do. The trust patients place in us inspires us to act with integrityand transparency as we strive for excellence each and everyday in all that we do.To learn more about Advanced Bionics visit AdvancedBionics.com

Advanced Bionics

Tools for SchoolsToday’s presentation is just one of many valuable FREEresources provided by Advanced Bionics’ Tools forSchools program (TFS ).The goal of the TFS program is to: Help school aged children with cochlear implants succeed inthe classroom. Ease your workload and save you time. Educate parents and professionals about CI technology. Provide support for effective teaming between the School, CIcenter and Home.Visit www.advancedbionics./tfs to learn more.

Common Expectations after Cochlear Implantation (CI) Improved hearing detectionthresholds Improved speech intelligibility Use of spoken language as theprimary mode of communication Improved language skills Improved reading skills Potential for mainstream educationwith normal-hearing children

What you will learn today Factors that influence performancein children Helping a child with a CI reach theirfull potential

Factors that Influence Performance Age at onset of deafness Age at time of implantation Consistency of device use Bilateral/bimodal device use Educational environment Family support and follow up Residual hearing Etiology Additional Special Needs Other Considerations

Factors that Influence PerformanceAge at onset of deafnessPre-lingually deafened children lost ability to hear before learning to understand & speak a language limited experience with sound and oral language poorer auditory memoryPost-lingually deafened children lost ability to hear after learning to understand & speak a language greater experience with sound and oral language better auditory memory

Factors that Influence PerformanceAge at time of implantation Younger Children (12 months – 2 years)– critical period for learning language– bond quicker to the device– auditory plasticity Older children– length of deafness is greater– increased risk for non-use

Factors that Influence PerformanceBilateral/Bimodal Device Use Improved hearing in noise Improved hearing in quiet Improved lateralization & localization Assurance that the “better listening” ear iscaptured

Factors that Influence PerformanceConsistency of device use Every day, all waking hours is critical Consistent use contributes toincreased performance Inconsistent use discourages devicebonding and encourages non-use

Factors that Influence PerformanceEducational Environment Support and maintain the CI Educate those involved with the child Provision of an optimal auditory environment– FM System– Classroom acoustics Promotes and encourages auditorydevelopment

Factors that InfluencePerformanceFamily support and follow-up Consistent Follow Up– Regular visits to theaudiologist Equipment Maintenance– Provide optimal listeningconditions Create a Listening Rich HomeEnvironment

Factors that InfluencePerformancePrevious Auditory Experience Length of deafness is shorter Better auditory memory for sound Auditory nerve survival may begreater Residual hearing provides a“bank” of auditory experiences

Factors that InfluencePerformanceEtiologyCongenital abnormalities– Mondini malformationAcquired abnormalities– Ossification (Meningitis)Abnormalities in the inner ear mayincrease the difficulty of the surgery– May prevent a full insertion ofelectrode array– May restrict cochlear implantfunction

Factors that InfluencePerformancePhysiology Presence of full auditorynerve bundle Compromised auditorypathway Auditory cortex

Factors that InfluencePerformanceAdditional Special NeedsCognitive conditions Auditory ProcessingProblems Learning Disabilities Neurological ProblemsNon cognitive conditions Blindness Cerebral Palsy

Factors that InfluencePerformanceConsiderations for Additional Complex Needs: Progress is slower but often still follows that of a childwithout additional challenges Progress is dependent on individual- Often requires multi-modality approach to optimizelanguage Cochlear implant will not “cure” the otherdevelopmental issues Multi-disciplinary approach is important

Factors that InfluencePerformanceOther considerations Child’s desire for the cochlearimplant Child’s drive to communicate Child’s behavior

What you will learn today Factors that influence CI performance inchildren. Helping a child with a CI reach their fullpotential.

Achieving Full PotentialCreate a Plan Set Goals and Expectations Auditory Integration Monitor Progress Educate professionals

Setting Goals What are the goals?Language rich environmentHelping the child tounderstand what they arehearingHelping the child to developspoken language skillsHelping the child gainindependence and selfconfidence

Setting GoalsWhat is the appropriate CommunicationGoal?Fully VisualQuite VisualEqually Visualand AuditoryQuite AuditoryFullyAuditory

Setting Goals Use your Experience as Guidance forSetting Goals and Expectations– Educational experience with otherchildren with hearing loss– Experience with other children withCochlear Implants

Setting Goals forLanguage DevelopmentResearch has shown: After implantation, children should make at least oneyear of language growth for each year of cochlearimplant experience Early implantation (prior to age 2 years) may not onlyprevent increased language delays, but may in facthelp to eliminate them Children implanted prior to 2 years understandvocabulary and develop language skills faster thanlater-implanted children Communication skills improve significantly withincreased cochlear implant useKirk, K., Miyamoto, R., Ying, E., Perdew, A., & Zuganelis, H. (2002) Does Age Matter with Cochlear Implants? CochlearImplantation in Young Children: Effects of Age at Implantation and Communication Mode, The Volta Review, VolumeNumber, Page Range. Retrieved .aspx?id 455#sthash.59aGjZ5e.dpuf

Setting Goals forLanguage DevelopmentRate of Language GrowthExpectedchanges inlanguage for achild implantedat age 4 years.1816Age Equivalent141210Hearing Aids8Cochlear Implant6No loss420246810121416Age in yearsKirk, K., Miyamoto, R., Ying, E., Perdew, A., & Zuganelis, H. (2002) Does Age Matter with Cochlear Implants? CochlearImplantation in Young Children: Effects of Age at Implantation and Communication Mode, The Volta Review, VolumeNumber, Page Range. Retrieved .aspx?id 455#sthash.59aGjZ5e.dpuf

Achieving Full PotentialCreate a Plan Set Goals and Expectations Auditory Integration Monitor Progress Educate professionals

Auditory IntegrationEven though the cochlearimplant makes soundavailable to a child’sauditory system, the childmust be taught to makemeaningful use of thisauditory information.

Auditory IntegrationComponents of Auditory Integration Consistently communicate that sound has meaningMaintain strong expectations for listeningReduce predictabilityParticipate with student’s therapists and parents to bridgeactivities into the child’s real lifeIntegrate language goals into auditory classroomactivitiesIntegrate the process of listening, speaking, and thinking

Auditory IntegrationSound Has Meaning Allow time for a child to process what was heard beforeexpecting a response Practice using the auditory sandwich by: first, describingconcepts or talking about an activity; then, allow timefor thinking about what was heard; finally, demonstrateor show, and finish with a spoken statement Use prompts, “Did you understand me or are you stillthinking?” and encourage asking for clarification Encourage commenting on things that the child hearsor that others say

Auditory IntegrationStrong Expectations for Listening Give opportunities for children to self-monitor spokenlanguage through listening– After giving directions, ask children to restate the directionsfor an activity or provide the next step– Encourage responding to what a classmate has said Use hearing peers as models Purposeful sabotage– Say one thing and do another and ask for clarification ofwhat was said and what should have been done

Auditory IntegrationReduce Predictability Use new vocabulary for the sameword/activity (get out your writinginstrument vs. pencil) Use different speakers (student vs.teacher reading out loud) Sabotage a spoken direction usedduring a common classroom routine (sayone thing and do another) Change the expected order of events ina schedule to check for listening

Auditory IntegrationBridge Activities Collaborate with Parents and Therapists:– Share classroom themes/content with parents &therapists for extension listening and languageactivities at home and during therapy– Send vocabulary lists and spelling words to home &therapy– Integrate listening and language goals from therapyinto classroom Use examples from child’s daily living to explainnew concepts in the classroom Help connect new knowledge to lifeexperiences

Auditory IntegrationIntegrate Goals into the Classroom Ask parents and therapists for goals and plan foractivities to practice speech, listening, and languagegoals using classroom content Provide frequent opportunities to rehearseconcepts/directions presented in the classroom Encourage use of metalinguistic strategies in theclassroom: self-talk, predicting, paraphrasing, andsummarizing Invite the Hearing Itinerant teacher to observe andmake suggestions for opportunities to integrate listeninginto the classroom

Auditory IntegrationIntegrate Listening, Speaking, Thinking Model and practice thinking out loud during classroomactivities Create opportunities to talk about new topics or expandknowledge of known topics Take advantage of teachable moments by usingincidental learning opportunities to teach language, focuson listening, and increase knowledge of the world Explore and learn about new topics through reading,going, doing, and discussing Take opportunities to use figures of speech and discusswhat is heard and what is meant (“That was a slamdunk!”)

Achieving Full PotentialCreate a Plan Setting Goals and Expectations Auditory Integration Monitor Progress Educate professionals

Monitor ProgressProgress should be monitored at regular intervals-How is child progressing compared to preimplant performance?-How is child doing compared to other similarchildren with cochlear implants?-How is child doing compared to normallyhearing peers?- Is child meeting set goals?

Monitor ProgressHow to Monitor Progress Formal Evaluations Auditory Benchmarks Red Flags

Monitor ProgressFormal evaluations Commonly completed by CI CenterAssess auditory thresholdsAssess speech perception abilitiesAssess understanding, use of language, andspeech production abilities

Monitor ProgressFormal EvaluationsPost CI AUDIOGRAMAfter a few months ofexperience, mostchildren can detectsound in the normal tomild hearing loss range.Goals should be set totake advantage of thechild’s improved sounddetection abilities

Monitor ProgressKeep in mind the ability to detect asound confirms audibility along thefrequency spectrum butAudibility does not understanding

Monitor ProgressFormal EvaluationsSpeech Perception Testing Provide information on the child's ability toperceive and process auditory messages Assess children at different levels of skilldevelopment Demonstrate progress over time.Assessing Listening Skills in Children with Cochlear Implants: Guidance for Speech-Language Pathologistsby Linda I. Rosa-Lugo & Susan G. AllenThe ASHA Leader March 15, 2011

Monitor ProgressSpeech Perception TestsResponses during this type oftesting: Indicates understandability inan ideal listening environment Does not indicate “realworld” understandability(noise, distance, soft voices)

Monitor ProgressFormal EvaluationsMany centers will complete formal speech andlanguage evaluations to track the child’s progress inspeech production and language development

Monitor ProgressHow to Monitor Progress Formal Evaluations Auditory Benchmarks Red Flags

Monitor ProgressAuditory BenchmarksAuditory Benchmarks for progress have beendeveloped using research results. Provides average data to measure progress Provides information on variables that canaffect progress Assists when counseling family and others

Monitor ProgressAuditory Benchmarks Pre-implant characteristics predict post CI outcomesGROUP 1 Implanted in the preschool years.GROUP 2 Implanted at age 5 or later.Some residual hearing and speech perception skills.Consistent use of hearing aids.Communicates primarily through speech.GROUP 3 Implanted at age 5 or later.Little or no residual hearing or speech perception skills.Highly dependent on sign.McConkey-Robbins, A. (2005). Clinical Red Flags for Slow Progress in Children withCochlear Implants. Loud & Clear!, 1, 1-8.

Monitor ProgressAuditory BenchmarksGroup 1 – Preschool1 MonthFull time implant use without resistance.3 MonthsChanges noted in vocalizations6 MonthsSpontaneous response to name and commonenvironmental sounds12 MonthsAttaches meaning to sound

Monitor ProgressAuditory BenchmarksGroup 2 – 5 years or older & residual hearing1 MonthFull time implant use without resistance3 MonthsClosed set understanding of some familiar words6 Months Understands many familiar words in a closed set Spontaneously alerts to name Understands some familiar phrases12 Months Spontaneous response to own name vs. others Auditory recognition of some sounds at school

Monitor ProgressAuditory BenchmarksGroup 3 – 5 years or older & limited or no auditory experience1 MonthFull time implant use without resistance3 MonthsDiscriminates patterns of speech6 Months Understands a few words in closed set Alerts spontaneously to loud noises Begins to detect name spontaneously Reports dead battery some of the time12 Months Understands many words in closed-set May understand familiar phrases Knows when device is not working Spontaneously responds to name about half the time

Monitor ProgressAuditory BenchmarksProvide: Outcomes data for a large number of implantrecipients Information on “typical performance”However Outliers are a reality Each person brings their own individualhearing health history and personal attributesto the implant experience

Monitor ProgressHow to Monitor Progress Formal Evaluations Auditory Benchmarks Red Flags

Monitor ProgressRed Flags Set up brief meetings between educators andparents every 3 months the first year afterimplantation Identify “red-flags” for children who are notprogressing appropriately.

Monitor ProgressWhat is a red flag? Concern that is raised over a child’sinadequate progress with a cochlearimplant Severity of the concern relates to: The length of the delay The number of skills delayedMcConkey-Robbins, A. (2005). Clinical Red Flags for Slow Progress in Children withCochlear Implants. Loud & Clear!, 1, 1-8.

Monitor ProgressExamples of Red FlagsDecrease in speech perception abilityDecrease in speech production skillsSudden resistance to wear the deviceSudden change in attention or behaviorConstant “fiddling” with the speech processorLack of progress over a period of timeSudden decline in progress documented over severalsessions Failure to meet expected goal or auditorybenchmark

Monitor ProgressUse this TFS Resourceto help you trackprogress and monitorred flags

Monitor ProgressResponding to Red FlagsMcConkey-Robbins, A. (2005). Clinical Red Flags for Slow Progress in Children with Cochlear Implants.Loud & Clear!, 1, 1-8.

Monitor ProgressFor some children Red Flags may indicate Lack of consistent device useThe need for programming changesEquipment issuesThe need for a communication environment inwhich listening and speech are addressedappropriately on a daily basis.McConkey-Robbins, A. (2005). Clinical Red Flags for Slow Progress in Children with Cochlear Implants. Loud& Clear!, 1, 1-8.

Monitor ProgressFor some children Red Flags may indicate An underlying cognitive issue which makes thechild a slower learner– A multidisciplinary evaluation may provide valuableinformation– More time may be required at each level ofinstruction– These children should keep moving along theauditory continuum, even if at a slower rate.McConkey-Robbins, A. (2005). Clinical Red Flags for Slow Progress in Children with Cochlear Implants. Loud &Clear!, 1, 1-8.

Monitor ProgressKeep in Mind Group performance data only provide guidance forsetting expectations Your work, ultimately focuses on the individual child Each child may represent the exception, not the rule Set and maintain expectations that take into accountthe unique abilities and life circumstances of each childand his or her family Be flexible and willing to change goals Know when to contact the cochlear implant center(Tools for Schools has forms to assist you in communicating with thecochlear implant center)McConkey-Robbins, A. (2005). Clinical Red Flags for Slow Progress in Children with Cochlear Implants. Loud &Clear!, 1, 1-8.

Achieving Full PotentialCreate a Plan Set Goals and Expectations Auditory Integration Monitor Progress Professional Education

Professional Education Understand what acochlear implant is andhow it functionsUnderstand how tocomplete troubleshootingKnow where to find supportand resource materialsCommunicate with yourstudent’s cochlear implantcenter

Summary Outcomes after cochlear implantation are individual anddepend on the many factors that influence performance There are many ways to assist children in reaching their fullpotential with a CI Set appropriate goals and expectations Use Auditory Integration Monitor progress Be aware of red flags Communicate with your team members at school andyour CI Center Adjust expectations as appropriate Educate yourself and other professionals

Her cochlear implants allow her to participate in many different StudentCouncil activities that involve being in social settings. She feels part of agroup and not like an outsider. Most importantly her friends and peerssee her as Addison, the funny, kind hearted, smart young lady that she isand not the “girl with the bionic ears.”—Rachelle Blackmon, mother of Addison, bilateral AB recipient

AB Makes itSimple for SchoolsFREE resources!!www.advancedbionics.com/tfs

Tools for Toddlers ProgramDo you know about Advanced Bionics’Tools for Toddlers program (TFT )?TFT provides free resources createdspecifically to help support earlyintervention and pre-school agedchildren.Visit the Tools for ToddlersProgram atwww.advancedbionics.com/tfsTFT resources can be found on thelower section of the TFS page

AB Makes ItSimple for SchoolsAdditional FREE Resources www.hearingjourney.com www.thelisteningroom.com www.advancedbionics.com/bea www.advancedbioinics.com– Take free courses– Learn about products– Watch videos– Download materials andresources– Connect with others

Additional Resourcesand SupportCustomer Care:Speak with an audiologist:Toll Free Phone: 1-877-829-0026TTY: 1-800-678-3575Email ancedBionics.comhear@AdvancedBionics.comMonday through Friday, 5 am to 5 pm PST

Cochlear Implant No loss Age in years t Expected changes in language for a child implanted at age 4 years. Setting Goals for Language Development Kirk, K., Miyamoto, R., Ying, E., Perdew, A., & Zuganelis, H. (2002) Does Age Matter with Cochlear Implants? Cochlear

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