Conductive Hearing Loss

1
Welcome
Please register help yourself to handouts
see if you can label parts of the ear while you
wait sit and relax
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CONDUCTIVEHEARING LOSS
Introducing the resource kit Do You Hear What I
Hear?
YOUR NAME, POSITION AND TELEPHONE NUMBER
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Outcomes

• Examined the causes, signs and symptoms of
  Conductive Hearing Loss (CHL)
• Explored the impact of CHL on childrens
  development and educational outcomes
• Become familiar with medical approaches to
  managing CHL
• Examined educational approaches for children with
  CHL, described in the kit Do You Hear What I
  Hear?
• Developed a plan for Where to from here?

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Context of the CHL Strategy
Dept of Health and other health providers
Curriculum Framework
Building Inclusive Schools
Students at Educational Risk
Aboriginal Education Operational Plan
NIELNS
Conductive Hearing Loss
Speech Language Plan
ILSS 2 Way Learning ESL/ESD
WAIDE
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Principle of Inclusivity
means providing all groups of students,
irrespective of educational setting, with access
to a wide and empowering range of knowledge,
skills and values recognising and accommodating
the different starting points, learning rates and
previous experiences valuing and including the
understandings and knowledge of all groups
providing opportunities for students to evaluate
how concepts and constructions such as culture,
disability, race, class and gender are
shaped. Curriculum Framework, 1998, p. 17
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CHL Resourcing

• Consultants (2), Aboriginal Health and Education
  (including CHL, Nutrition, Substance Use, Mental
  Health, Family Violence) Statewide
• Do You Hear What I Hear? One kit available to
  each school and distributed through professional
  development programme
• Funding

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Do You Hear What I Hear?

• Intervention Strategies for Aboriginal Children
  with CHL research report, intervention plan and
  case studies of two focus schools
• Resource Book introduction to CHL impact of
  CHL on language, literacy and social-emotional
  development management of CHL in schools
  teaching and learning strategies profile and
  screening tool
• CD-Rom as above plus an interactive childrens
  section
• Masters for activities and a certificate for
  Breathe, Blow, Cough (BBC)
• Posters (2) Understanding Middle Ear
  Infections and How to Avoid Ear Infections
• Stickers
• Order form for kit

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Situation of the Ear
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Situation of the Ear
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Anatomy of the Ear
Ossicles
Hammer, Anvil, Stirrup
Semicircular Canals
Pinna
Auditory (or Cochlear) Nerve
Cochlear
Inner Ear
Vestibule
External Auditory Canal
Tympanic Membrane (Ear Drum)
Eustachian Tube (to nose and throat)
Outer Ear
Middle Ear
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Types of Deafness

• Conductive Hearing Loss - an impairment to the
  physical mechanism of the outer and/or middle
  ear occurs as a result of trauma or Otitis Media
  (OM) OM is caused by colds, flu, large adenoids
  or tonsils, and allergies
• Sensorineural Loss results from damage to the
  auditory nerve or the workings of the inner ear
• Mixed Loss combination of conductive and
  sensorineural loss

NB Hearing impairment is not just a simple
reduction in auditory sensitivity. Perceived
sounds may be distorted.
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Incidence of Conductive Hearing Loss

• Specific populations show greater susceptibility
  Aboriginal children, Inuits (Eskimos), Apache
  and Navajo Indians, children with particular
  disabilities some evidence of higher prevalence
  in SE Asian and Hispanic children (Hasenstab,
  1987). Maori children (NZHTA, 1998).
• 75 to 80 of Aboriginal children on any one day
• 20 to 25 of European children on any one day

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What to do if you suspect a hearing loss

• Refer the child for assessment, which will
  determine
• If the child has a hearing loss
• What the degree and nature of the loss is
• How the hearing loss can be medically managed
  effectively

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Assessments that are conducted

• Audiometry (1 of 3)
• Air conduction screening
• - sound goes through middle ear
• Masked or unmasked tests
• Bone conduction screening
• - sound bypasses middle ear
• Specialised tests for young children, e.g.
  Distraction Test for babies conducted by Infant
  Health Nurses

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Audiogram for normal hearing
Pitch
Frequency in Cycles per Second (Hz)
125
250
500
1000
2000
4000
8000
0
10
20
Right ear Left ear
30
40
50
Volume
Hearing Level in Decibels (dB)
60
70
80
90
100
110
120
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Interpreting an Audiogram
Pitch
Frequency in Cycles per Second (Hz)
125
250
500
1000
2000
4000
8000
Very Soft
0
10
20
30
40
50
Volume
Hearing Level in Decibels (dB)
60
70
80
90
100
Very Loud
110
120
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Activity
Interpreting an audiogram
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Audiogram of Familiar Sounds
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Mild Hearing Loss
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Understanding Degrees of Hearing Loss
Mild (26 44 dB)
Moderate (45 59 dB)

• Understand conversation at 1 1.5m
• May have delayed speech development
• May miss up to 50 class discussion if
• speaker not visible
• May need hearing aid
• Will need special education attention

• Understand conversation at 0.5m
• Will have difficulty at school
• Likely to have language delay
• Will have poor speech clarity
• Will need hearing aid
• Will need special education assistance and
  probably special training for listening

Severe (60 89 dB)

• May understand speech at lt15cm
• Hears loud environmental sounds
• Will have delayed speech/language
• Will need hearing aid
• Requires auditory training
• Uses vision for additional cues
• Speech/language will not develop
• spontaneously if loss present before
• 1 year old

Profound (gt 90 dB)

• May only be aware of very loud sounds
• Speech and language will be defective
• Visual and gestured cues essential for
• learning
• Needs full time special education
• assistance
• Use of a hearing aid

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Assessments that are conducted

• Tympanometry (2 of 3)
• Assesses status and function of middle ear

• Looking for the following
• Is the eardrum intact?
• Is the middle ear system mobile/immobile/partly
  mobile?

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Assessments that are conducted

• Otoscopy (3 of 3)
• Examines the appearance and texture of the
  eardrum
• Screening otoscopy checks for blocked ear canal,
  state of eardrum and presence of fluid in middle
  ear
• Diagnostic otoscopy differentiates between the
  different types of Otitis Media

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Normal Eardrum

• Thin and semi-transparent
• Pearly-grey appearance
• Often some structures within the middle ear can
  be seen
• A cone of light extends downwards and forwards
  from the umbo (where the eardrum attaches to the
  malleus or hammer)

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Types of Otitis Media

• Acute Otitis Media - An acute infection of the
  middle ear and eardrum. Starts suddenly, may be
  caused by bacteria, viruses or a combination.
  Children may have ear pain, fever, rub or pull
  their ears, may be irritable, cry, lose their
  appetite, vomit or have diarrhoea. Eardrum can be
  bulging and may/may not be red, and may not move
  as it should.
• Some children, however, may not show signs of
  this infection!

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Types of Otitis Media

• Otitis Media with effusion, Glue ear Fluid in
  the middle ear, the consistency of egg white.
  Distortion of the eardrum, prominent blood
  vessels and bulging in upper half, dullness in
  lower half. Outline of malleus (hammer) is
  obscured. Fluid levels can be seen behind the
  drum.
• Some children may complain of ear pain, but
  dont have the signs and symptoms of Acute Otitis
  Media.

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Types of Otitis Media

• Chronic Supparative Otitis Media, Runny ear
  Serious and persistent infection. Hole in eardrum
  and pus flows from middle ear into canal. Usually
  follows untreated or poorly treated acute middle
  ear infection. Often occurs in children under 5
  and in children who live in poverty and poor
  environmental conditions. Ear pain not common.
  Without treatment damage to middle ear bones will
  occur and increasing hearing loss. May also cause
  serious infections in mastoid bone and in brain.

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Impact of Otitis Media is Multi-Factorial

• Age at which the child experienced the first
  incidence of OM
• Number of incidences under the age of 12 months
• Access to good medical intervention
• Access to certain types of interactions within
  the family
• Access to audiology and speech pathology
• Childs general health

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Activity
So whats it like to have CHL?
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Morning Tea
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Medical Treatment

• Glue ear and infections often clear up without
  treatment
• Antibiotics will help with an infection but will
  not clear up the fluid build up that occurs with
  glue ear
• Runny ear does not clear up quickly or easily.
  The recommended treatment is twice daily
  syringing with Betadine, followed by dry mopping,
  then drops, for 16 weeks.

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Surgical Treatment
Grommets are recommended for children who have
had more than 6 infections in a year or one bout
of Otitis Media lasting more than 3 months
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More Surgical Treatment

• Myringoplasty / Tympanoplasty patches the
  eardrum not suitable for runny ears
• Mastoidectomy removal of part of mastoid bone
  and other parts of middle ear because of erosion
  by fluid over long period of time
• Middle ear reconstruction

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Amplification Options
Behind-the-ear style sits behind ear, amplified
sound travels down a tube into customised
earmold In-the-ear hearing aids fit inside
ear In-the-canal hearing aids are smaller and
fit the size and shape of ear canal Completely-in
-the-canal hearing aid is worn deep inside canal
and are almost invisible.
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Other Amplification Options

• Hearing hats/head bands bone conduction
• Personal FM systems
• Sound Field Amplification Systems

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Modes of Communication
Speaking and listening
Reading and writing
Pitch, rhythm and intonation
Gesturing and body language
Signing
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Speech and Language

• Speech the sounds of a language the ability to
  pronounce and distinguish different sounds and
  the ability to coordinate the voice box, lips and
  tongue to produce sounds
• Language the spoken, written or other symbol
  system used to convey (expressive) or understand
  (receptive) meaning

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Activity
Communicating without speaking
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Oral Language is fundamental
Speaking and listening provide the foundation for
all language learning and underpin the successful
development of reading and writing
skills. Proficiency in speaking and listening
contributes to childrens abilities to learn
effectively in all learning areas. First Steps
Oral Language Developmental Continuum
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Cultural Considerations

• Language is the repository of the speakers
  cultural knowledge and reflects their world view.
  When we devalue a language we devalue everything
  contained within and reflected by it.
• The Western school system is set up to reflect a
  literate tradition. It assumes all children come
  to school knowing how to work with language in a
  de-contextualised manner. We need to be aware
  that children may come to school with rich
  language experiences from predominately oral
  traditions and cultures.

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Impact of CHL on Speechand Language Development

• Hearing children learn the basics of language
  passively, by hearing it. This avenue is not open
  to children with hearing losses.
• Creates a barrier for normal speech development
  and phonological processing
• Causes delays in the development of a childs
  first language and any additional language,
  particularly when the hearing loss begins at a
  very young age
• Poor vocabulary and semantic organisation
• Expressive and receptive language difficulties
  language structure, word endings, grammar,
  word order etc.
• For Aboriginal children, diminished auditory
  experiences can affect opportunities for learning
  about culture, law, relationships, etc. (Clarke,
  1992)

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Impact of CHL on Comprehension
Oral comprehension relates to the ability to
understand the meaning of what is spoken.
Comprehension is dependent upon context, previous
knowledge and experience, sentence length,
concepts and attention. (adapted from Health
Department of WA Teacher Modules, 2000)

• A child with CHL or a history of CHL probably
  has
• Difficulty with lengthy or complex instructions
• An underdeveloped vocabulary including concepts
  and descriptive terms (e.g. in Preprimary will
  not understand concepts such as location
  over/under or size, and descriptive terms
  colour, shape)
• Difficulty with some questions (e.g. in
  Preprimary cant understand wh questions who,
  what, when, where)

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Impact of CHL on Semantics
Semantics refers to the link between our thoughts
and ideas and the vocabulary and concepts we use
to express these thoughts. Semantic organisation
describes how we organise incoming information in
order to make sense of and later retrieve
it. (adapted from Health Department of WA Teacher
Modules, 2000 Holt Spitz, 2000)

• In Preprimary, a child with CHL or a history of
  CHL probably
• Has a vocabulary of less than 1500 words
• Speaks in sentences of lt 3 to 5 words
• Doesnt use language socially
• Is slow to learn words and concepts (due to
  fuzzy representations)

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Impact of CHL on Semantics

• Other indicators may be
• Difficulty integrating new information with
  existing
• Limited conceptual understanding
• Under-developed receptive and expressive
  vocabulary
• Difficulty retrieving words
• Difficulty generating ideas related to a topic
• Conversational difficulties

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Impact of CHL on Syntax
Syntax or grammar refers to the way we organise
words into sentences. Grammatical rules tell us
which words should come before or after others,
the word endings we should use and the way words
combine to form sentences. (adapted from Health
Department of WA Teacher Modules, 2000 Holt
Spitz, 2000 Owens 1992)

• Problems with forming linguistic categories such
  as plurals and tenses
• Grammatical errors and unusual word order
• Incomplete sentences
• Restricted use of describing words
  (adjectives/adverbs) and connectors (but, then,
  because, so )

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Impact of CHL on Narrative(Oral Texts) Skills
Narratives/Oral texts encompass such genres as
stories, reports, procedures, explanations,
recounts and news telling. The common feature of
these genres is the linguistic structures that
are used to tell and retell a series of events in
time order. (Adapted from Health Department of
Western Australia Teacher Modules, 2000 Holt
Spitz, 2000)
The Western-style narrative structure tends to be
linear in nature and uses a distinct model that
may be difficult to understand for Aboriginal and
other CALD students. If a child has hearing
problems they are likely to have additional
problems with story grammar and descriptive
vocabulary.
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Impact of CHL on Phonological Processing
Phonological processing relates to the ability to
use the sounds of a language to process oral and
written language, which allows us to form
phonological codes and access a word stored in
our brains lexicon. Phonological awareness
skills (explicit awareness of sound structure and
ability to manipulate structure of words) are
dependent on phonological processing skills.

• Need to hear words to learn words to map
  words to objects
• car? ar? bar? tar?
• Absence of second sound in two-letter blend (eg
  frog, block)
• Absence of unstressed syllable(s) (banana,
  dinosaur, balloon)
• Poor discrimination and identification of sounds

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Impact of CHL on Phonological Processing
Australian English speech sounds with which
ESL/ESD speakers frequently are not familiar
Consider the similarities between these sounds
(voice, placement of lips and tongue). If a
child cant hear a sound correctly he/she will
have considerable difficulty learning to say it
correctly, particularly if he/she is reliant on
visual differentiation.
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Impact of CHL on Metalinguistic Skills
Metalinguistics refers to the ability to use
language to think, talk about, reflect on and
manipulate units of language.

• Dont know how to play with sounds and words, eg
  rhyming
• Dont know what a word is so have difficulty
  understanding word boundaries and segmenting
  sentences into words Ontheweekend, smorning

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Impact of CHL on Metalinguistic Skills

• Difficulty manipulating words within words (eg
  take sun from sunshine) syllables in words (eg
  take ing from doing) sounds in words (eg boat
  has 3 sounds b / oa / t take c from coat)
  and blending sounds to make words (eg s t o
  p)
• Poor understanding that words are arbitrary
  symbols of a language system words usually
  dont contain any hint of their meaning
• Problems working out how communication breaks down

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Impact of CHL on Pragmatics
Pragmatics relates to the use and functions of
language for communication. Pragmatic awareness
is the knowledge of conversational rules and
includes both verbal and non-verbal
aspects. (adapted from Holt Spitz, 2000 Owens
1992)
Children with a hearing difficulties may have
problems with

• Entering into a group, requesting, responding and
  taking turns
• Initiating conversations
• Understanding subtle social rules
• Accepting others points of view and others
  feelings
• Monitoring the listener

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Impact of Hearing Loss on Socialisation
Children with hearing difficulties, however, are
also likely to present with social and emotional
challenges due to

• Their own frustration and/or the frustration of
  their peers
• Avoidance
• Just not getting it i.e. the subtleties and
  unwritten rules of social exchanges

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Activity
Consider a child you know who has a
suspected/confirmed hearing loss. What
difficulties have you observed? What are some
strategies that have been effective with this
child?
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Summary of Educational Impact of CHL

• More than three infections under the age of 12
  months is a significant risk factor
• Even without a current ear infection children can
  still suffer the effects of a history of
  conductive hearing loss
• Poor ability to discriminate sounds in words and
  to hear words in words difficulty chunking words
  into individual parts and relationship between
  own sound repertoire and written alphabet is
  tenuous
• Language learning difficult frequently have
  restricted content, vocabulary, language and
  confidence prediction as a reading strategy is
  not functional except with simple or familiar
  texts
• Poor foundation for literacy and without help
  will fall further behind every year
• Socialisation difficulties and behaviour problems
  are likely
• The most debilitating aspects of deafness are
  secondary to the hearing impairment itself

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Lunch
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Activity
Strategies 1 to 6
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Strategy 1
Organise your classroom to maximise learning
for children with conductive hearing loss.
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Strategy 2
Increase childrens understanding of hearing
problems.
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Strategy 3

• Focus on oral language skills as the foundation
  for literacy.

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Strategy 4
Focus on spoken sound systems.
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Strategy 5
Link sounds to the written code.
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Strategy 6
Analyse spelling errors to inform teaching.
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Strategy 7
Implement a peer tutor program.
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Conductive Hearing Loss Screening Tool
Developed by Aboriginal and Torres Strait
Islander Education Support Unit
Learning Identifiers
Behavioural Identifiers
Has learning difficulties
Fidgets
Demands a lot of teacher attention
Easily distracted
Short attention span
Appears not be listening
Poor auditory memory and sequencing
Poor socialisation skills
Poor auditory association
Aggressive
Delayed language development
Bullying
Delayed gross motor
Erratic
Tends to respond to auditory clues only when
given visual clues as well
Inattentive
Physical Identifiers
Often says what
Redness around the ear
Does not respond when asked questions
Responds in inappropriately
Rubbing or pulling on the ear
Cupping the ear
Is slow to respond to instructions
Runny ear
Watches other children to see what to do
Ooze from the ear
Asks peers for confirmation what has been said
Re-occurring ear and chest infections
Sits close to the TV, etc
Sits on the outside so no expectation to
participate
Complaining of sore ears and throat
Puts head to the side as if to shake out fluid
Quiet voice
Mouth breather
Appears confused when there is a lot of noise
Poor gross motor skills
Is upset by loud or sudden noise
Often tired
Holds ears when there is excessive noise levels
Asks for the volume on the TV to be turned up or
down
Speech Identifiers
Mood changes when there is lots of noise
Speaks in soft or loud voice
Has been absent lots of times
Loses interest during story time or direct
instructions
Difficulty in understanding speech
Difficulty communicating feelings
Erratic classroom behaviour
Language development below age
Reluctant to participate
Obvious indication that the child watches your
face to lip read
Confusion of words
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Summary of Key Teacher Behaviours

• Teamwork including the AIEO, district CIOs,
  audiologist/speech pathologist/psychologist/occupa
  tional therapist.
• Point of error analysis to understand the
  strength and weaknesses of a childs system.
• Practice at the phonological level and oral level
  before moving into the written code.
• Research has shown that a drill orientation
  program works well with young children while the
  meta approach is most effective with older
  students.
• Use practice, repetition, buddying, small group
  work, pre-teaching and one-to-one tutoring as
  tools.
• Investigate amplification.

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Model for Effective Practice in Schools
Curriculum, teaching and learning
School organisation, ethos and environment
Whole School Approaches Targeted Approaches for
Groups Targeted Approaches for
Individuals Individual Case Work
Partnerships and services
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Health Promoting Schools Framework
Curriculum, teaching and learning
School organisation, ethos and environment
Policy, planning and processes Professional
development Collaborative planning Safe,
supportive and inclusive environment
Strategies 1 to 7 IEPs
Parents, carers, family members school health
AIEOs, ALOs, C/MAEs school psychologists
specialist teachers visiting teachers
audiologists speech pathologists medical
personnel
Partnerships and services
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Where to from here?

• Consider
• your school and/or district and community
• further professional development needs
• the need for others to acquire knowledge and
  skills
• partnerships that are already in place
• opportunities to create new partnerships
• Identify the first three steps that need to be
  taken in your school community or at a local
  level to improve outcomes for children who are
  experiencing or have experienced CHL.

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Evaluation Time!
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Thank you and close