Introduction to AR

Perry C. Hanavan, Au.D.

Audiologist

TED Talk

• Establishing a Sound Foundation

• Dr. Karl R. White is a Professor of Psychology at Utah State University and the founding Director of the National Center for Hearing Assessment and Management (NCHAM).

• Recognized as one of the world's leading authorities on early identification and treatment of hearing loss in infants and young children.

• He has hundreds of publications and presentations at scholarly meetings, and has been invited to more than 30 countries to assist in the implementation of newborn hearing screening and intervention programs. 

Case Studies

• Newborn identified at birth with connexin 26, severe to profound bilateral hearing loss, normal hearing parents

• Newborn identified at 2 years with rapidly progressive bilateral SNHL, parents have a profound loss

• Seven year old recently identified with unilateral severe SNHL

• Middle school male with normal hearing but auditory processing problem in noise

• Fourteen year recently survived bacterial meningitis resulting in bilateral SNHL

• Dad, suffered sudden onset mild bilateral SNHL• Grandmother, slow progressive bilateral SNHL

Impact of HL on Quality of Life

• Physical health• Emotional & mental health• Other’s perceptions of a person’s mental acuity• Social skills• Family relationships• Self-esteem• Work & school performance• Household income by up to $12,000/year

Some Historical Landmarks Regarding AR in Audiology

• Genesis in WWII (1942)• Audiologists Dispense Hearing Aids (1978)• WHO Classification (1980)• Cochlear Implants (1984 – FDA approval)• Early Newborn Identification (1990 – Joint

Comm)• Communication Therapy (1990+)• Neural Plasticity of the Auditory System (1995+)• WHO Classification (ICF, 2001)• Hearing Assistance Technologies (HAT) (2000+)

Question

AR increases income for persons with hearing loss?

Yes

No

Hearing Loss and Impact on Household Income

Kochkin, S (2010).The Hearing Journal. 63(10):19-24,26,28.

Treated Vs. Untreated HLImpact on Household Income

Kochkin, S (2010).The Hearing Journal. 63(10):19-24,26,28.

Mild HL Linked to Brain Atrophy in Older Adults

• Early intervention could prevent slide toward speech comprehension difficulties

• Research suggests that hearing sensitivity has cascading consequences for the neural processes supporting both perception and cognition

Definitions

• Auditory Training• Aural Rehabilitation• Audiological Rehabilitation• Speechreading • Lipreading• Communication Rehabilitation• Habilitation• Rehabilitation

AR Definition

“The assessment, intervention, and management of communicative consequences of hearing loss”

(unknown author)

ASHAAural rehabilitation refers to services and procedures for facilitating adequate receptive and expressive communication in individuals with hearing impairment. (ASHA, 1984, p. 37)

Audiologic/aural rehabilitation (AR) is an ecological, interactive process that facilitates one's ability to minimize or prevent the limitations and restrictions that auditory dysfunctions can impose on well-being and communication, including interpersonal, psychosocial, educational, and vocational functioning.

(American Speech-Language-Hearing Association. (2001). Knowledge and Skills Required for the Practice of Audiologic/Aural Rehabilitation [Knowledge and Skills)

David Hawkins

Anything that facilitates:1) hearing,

2) understanding of hearing loss,

3) coping strategies,

4) acceptance of hearing loss, and

5) involving communication partners.

(Hawkins, D. 2003)

Mark Ross

Any device, procedure, information, interaction, or therapy which lessens the communicative and psychosocial consequences of a hearing loss.

Ross, M., JARA, 1997

McCarthy & Culpepper

The purpose of an aural rehabilitation program is to focus on assisting hearing-impaired individuals in the realization of their optimal potential in communication, which is needed in educational, vocational, or social settings.

McCarthy & Culpepper, AJA, 1987, p. 305

Houston & Montgomery

"…the goal of aural rehabilitation for the adult is ambitious – to increase the likelihood, the level, of successful communication over the client’s lifetime."

Houston, K.T., and Montgomery, A.A. Auditory-visual integration: A practical approach. Seminars in Hearing, 18 (2), 1997.

JP Gagné

“Aural rehabilitation is aimed at restoring or optimizing a patient’s participation in activities that have been limited as a result of a hearing loss and also may be aimed at benefiting communication partners who engage in activities that include person with hearing loss.”

Gagné JP. Ear and Hearing. 2000, p36.

Arthur Boothroyd, Ph.D.

“Adult aural rehabilitation is here defined holistically as the reduction of hearing-loss-induced deficits of function, activity, participation, and quality of life through a combination of sensory management, instruction, perceptual training, and counseling.

Boothroyd A, Trends in Amplification, 2007, p63.

Aural Rehabilitation

Intervention aimed at minimizing and alleviating the communication difficulties associated with hearing loss.

(Tye-Murray N. Foundations of Aural Rehabilitation (video)

Audiologic Rehabilitation

“Any activity, method, resource, technology, and/or device that facilitates and/or enhances communication and participation in activities.”

Hanavan, PC, 2010

Conversational Fluency

“…relates to how smoothly conversation unfolds”

“the book’s central theme”

Tye-Murray N, Foundations of Aural Rehabilitation, p2. and preface, p ix.

Hearing-Related Disability

“…a loss of function imposed by hearing loss. The term denotes a multidimensional phenomenon.”

Tye-Murray, Foundations of Aural Rehabilitation, p2.

Summary of Definitions of ARand WHO 1980

• Often describes approaches rather than objectives/goal

• Hearing and communication oriented

• Medically oriented: eliminate (treat)

prescribe (cure)

(International Classification of Impairments, Disabilities and Handicap – ICIDH, WHO, 1980): Adapted from Gagne JP, 2007 ARA Institute, Louisville, KY.

International Classification of Functioning, Disability and Health

(ICF: WHO, 2001)Health Condition

(disorder/disease)

Body Structures& Functions

Activities(activity limitation)

Participation(participation restriction)

Environmental PersonalFactors Factors

ICF (WHO: 2001)

Disabilities is an umbrella term, covering impairments, activity limitations, and participation restrictions. – Thus disability is a complex phenomenon, reflecting an

interaction between features of a person’s body and features of the society in which he or she lives.

Question

Does “hearing impairment” means deaf, only?

Yes

No

ICF (WHO: 2001)

Hearing impairment is a broad term used to describe the loss of hearing in one or both ears. There are different levels of hearing impairment: hearing impairment refers to complete or partial loss of

the ability to hear from one or both ears. The level of impairment can be mild, moderate, severe or profound;

deafness refers to the complete loss of ability to hear from one or both ears.

ICF (WHO: 2001)Impairment is 'a loss or abnormality of body structure

or physiological or psychological function'

Activity limitation is 'the nature or extent of functioning at the level of the person'

Participation restriction is 'the nature or extent of a person’s involvement in life situations in relation to impairment, activities, health conditions, and contextual factors’

Health-related Quality of Life is 'the functional effect of an illness and its consequent therapy upon the patient.'

Satisfaction is the subjective assessment by the patient that his/her needs or expectations have been met.

Applying WHO Taxonomy to HL

• Anatomy and physiology: Physical and functional integrity, including integrity of outer ear, middle ear, cochlea, neural pathways to the brain, and the brain itself. A major concern is with the status of the cochlea. With older patients, integrity of neural structures is important.

• Function: Includes hearing threshold, dynamic range, frequency range, spectral and temporal resolution, acoustic pattern discrimination, direction and distance perception, attention, auditory working memory, processing speed, and ability to listen in noise.

Applying WHO Taxonomy to HL

• Activity: The use of this capacity—the things one wants or needs to do with hearing in the real world. Examples include being alerted by sound, monitoring the environment, recognizing and localizing events and deducing their significance, monitoring and controlling one's own speech, and enjoying auditory experiences. The activities of most concern, however, are perceiving the speech of others and engaging in spoken language communication.

• Participation: The contribution of these activities to daily life, include social interactions and relationships, employment, leisure, learning, control, creativity, etc.

ICF (WHO: 2001)

Psychological factors pertains to attitudes, self-image, motivation and assertiveness, etc.

Social factors are the viewpoint of society

Model of Hearing-Related Disability

Hearing Impairment

LifestyleListening aids

Communication activity

limitations

Participation restrictions

Physical environment

Psychosocial factors

Frequent communication

partner(s)

Tye-Murray N, Foundations of Aural Rehabilitation, p4.

Services Included in AR Plan

• Diagnosis & quantification of hearing loss

• Hearing assistance technologies

• Auditory training

• Communication strategies training

• Informational/educational counseling

• Personal adjustment counseling

• Psychological support

• Communication partner training

• Speechreading training

• Speech-language therapy

• Inservice training

Question

Which is provided by educator of the deaf and/or SLP?

A.Aural rehab

B.Audiologic rehab

C.Physical therapy

Aural Rehabilitation vs. Audiologic Rehabilitation

• Aural Rehabilitation– Broad breadth of services– Variety of professional providers

• Audiologic Rehabilitation– Narrow breadth of services– Audiology professional providers

Roles

Audiologist:

Audiologic Rehabilitation

• Audiologic diagnostic evaluation

• Fitting, dispensing and evaluation of hearing aids

• Mapping cochlear implants

• Evaluating, fitting and dispensing HAT

SLP/EDHH:

Aural Rehab

• Evaluating speech/language receptive and expressive abilities

• Treatment of speech/language disorders

• EDHH provides curriculum

Rehabilitation vs. Habilitation

• Rehabilitation– Restore lost function– Adults– Acquired hearing loss

• Habilitation– Develop skill not present beforehand– Infants/children– Congenital or pre-lingual onset

AR Service Locations

• University/College• Private Practice• Hospital• Community Center• Otologist’s office• Public/Private School• Self-help groups• School for the Deaf• Internet• Home with computer

AR Providers

• Audiologist

• Speech Language Pathologist

• Educator of the Deaf

• Communication Partner

Other Team Members

• ENT

• Parents

• Regular classroom teachers

• Psychology

• Geneticist

• Other specialties as necessary

Definition of Terms in Survey

Traditional Variables

• Time of Onset

• Degree of Loss

• Type of Loss

• Etiology

Question

Which is not a traditional variable for hearing loss?

1.Time of Onset

2.Rapidity of progression of hearing loss

3.Degree of Loss

4.Type of Loss

5.Etiology

Other Variables

• Progressive

• Acceptance

• Family support

• Time of identification

• Time for implementation of AR

• Intelligence

• Motivation

AR vs. Age of Client

• Newborns• Preschoolers• Grade school• Middle school• High school• Post secondary• Young adults• Middle age• Old age

Hearing Loss Incidence• 36 million persons in US have HL• 4,000,000 babies born in US annually• 1 of every 22 infants has some degree of HL• 1/1000 to 6/1000 born with HL• 1.3% of children who receive special ed services

were hard of hearing or deaf• 1 in 25 people under age 45• 1 in 10 by age 60

– Third most prevalent chronic problem in older persons

• 5% of world’s population, about 360 million people, including 328 million adults and 32 million children, have disabling hearing loss

Hearing Loss Projections

Kochkin, S. MarkeTrak VII: Hearing Loss Population Tops 31 Million People, The Hearing Review, Vol. 12(7) July 2005, pp. 16-29.

HL Prevalence and Age

Time of Onset

The Joint Committee on Infant Hearing (JCIH) Year 2000 Position Statement

• The American Academy of Audiology, the American Academy of Pediatrics, the American Speech-Language-Hearing Association, the Council on Education of the Deaf, and the Directors of Speech and Hearing Programs in State Health and Welfare Agencies have joined together to endorse universal detection of infants with hearing loss.

• The goal is that all infants with hearing loss will be identified before 3 months of age and receive intervention by 6 months of age.

Time of Onset

• Congenital• Prelingual• Postlingual• Deaf/deaf• Deafened• Adventitious• Sudden• Progressive

National Goal – Early Hearing Detection and

Intervention (EHDI)

• 1-3-6

• Screen hearing by one month

• Confirm hearing loss by three months

• Early intervention by six months

Percent of newborns screened for hearing loss

Degree of Hearing Loss

• Minimal

• Mild

• Moderate

• Moderately Severe

• Severe

• Profound

Common Etiologies

• Most of the hearing loss is genetic with over 30 autosomal recessive (70-80%), dominant (23-30%) and X-linked (2-3%) forms.

• A large proportion (60-75%) of nonsyndromic hearing loss in children has been localized to defects in a single gene, Connexin 26 (Cx26) on chromosome 13q11-12. – A variety of mutations have been described in this gene

with a 35delG hotspot mutation representing over half of the defects in Caucasians.

• Recently, other links with deafness and connexin has been established

Autosomal Recessive Non-Syndromic HL

Question

The Amy Tan Syndrome?

A.Treacher-Collins

B.BOR

C.Pendred

D.Stickler

E.Usher

Common Syndromes Associated with Hearing Loss

Name of syndrome Other features that may occur (besides hearing loss)

Alport Kidney problems

Branchio-oto-renal (BOR) Neck cysts and/or ear tags and kidney problems

Jervell and Lange-Nielsen Heart problems

Pendred Thyroid enlargement or low thyroid function

Stickler Unusual facial features, cleft palate, eye problems (nearsightedness, cataracts, or retinal detachment,) arthritis, heart problems

Usher Progressive blindness

Waardenburg White patch of hair or light-colored skin patches; eyes of two different colors, or bright blue eyes, or widely spaced eyes

Comorbidities

• Comorbidity is the -– presence of one or more disorders or diseases in

addition to the primary disease or disorder; or– effect of disorders or diseases

• Children with congenital SNHL have a relatively high incidence of comorbid conditions, either congenital or acquired

Etiologies

• Genetic– Autosomal, x-linked, mitochondrial, non-syndromic,

syndromic• Bacterial/viral• Metabolic• Trauma• Ototoxic• Cancers• Vascular disorders• Myelization

Type of Loss

• Conductive• Sensorineural• Mixed• Auditory Processing

Disorder

AR Service Plans

Home

VocationalSocial/

Avocational

Home

EducationalSocial/

Extracurricular

Adult Child

(Tye-Murray, 2009, p 16)

AR Services• Services for persons with hearing loss

– Served– Unserved– Underserved

• Lack of services due to– Lack of outreach and immediate or extended

support services– Attitudes of service delivery personnel– Lack of adequate reimbursement for AR– Communication and environmental barriers

(Tye-Murray, 2009, p 14)

Cost-Effectiveness and Costs

Cost-effectiveness is the relationship between the money spent and the benefits accrued

Cost is the actual expense for providing

Examples:

Trends in Educational Placement and Cost-Benefit Considerations in Children With Cochlear Implants

Reimbursement

Medicare U.S. Social Security program that reimburses hospitals and physicians for medical care provided to qualified persons 65 years or older (federal program)

Medicaid U.S. Title XIX program under the Social Security Act that is jointly funded by the federal and state governments that reimburses healthcare providers

Private insurance plans (some provide for services while others do not)

IDEA youth birth to twenty-one who qualify

Out of pocket payment

Triad of Evidence-Based Practice

Evidence-Based Practice. Developed with Keith Posley, MD, Stanford Medical ... medresidents.stanford.edu

Evidence-Based Practice

EBP is “the integration of best research evidence with clinical expertise and patient values

Levels of evidence to support EBP

Five-step approach (Canadian Cochrane Network/Centre Affiliate Representatives)

Question

How many persons that could benefit from wearing hearing aids in the U.S. have hearing aids?

A.1 in 5

B.1 in 3

C.1 in 4

D.1 in 6

Hearing Aid UseOnly 1 in 4 wear hearing aids who could benefit from amplification

S. Kochkin. MarkeTrak VIII: 25 year trends in the hearing health market. The Hearing Review, Vol. 16 (11), October 2009, pp.12-31.

Other Areas of AR

• Auditory processing disorders

• Tinnitus

• Hyperacusis

• Vestibular and balance disorders

AR Professional Organizations

• AAA (American Academy of Audiology)• AAS (American Auditory Society)• AG Bell Association• ARA (Academy of Rehabilitative Audiology)• ASHA (American Speech Language Hearing

Association)• EAA (Education Audiology Association) • ISA (International Society of Audiology)

AR Foundations

• DRF (Deafness Research Foundation)

Consumer Organizations

• HLAA (Hearing Loss Association of America)

• Hearing Loss Web

• ALDA (Association of Late-Deafened Adults)

• Hands & Voices

Terminology: Hearing Loss

• NAD– Deaf-mute, deaf and dumb, hearing impaired

terminology– d/Deaf

• Wikipedia• Hearing Loss Association of America• “Hard of Hearing,” “Hearing Impaired” or

“Deaf”—Which Is Correct?

Kiersey

Circle of Courage

• Belonging

• Independence

• Generosity

• Mastery