Natalia was diagnosed at birth with a sensorineural hearing loss and received a cochlear implant (CI) at the age of 3 years and 5 months. At 4 years old—after using the CI for seven months—Natalia entered a private school that provided intensive intervention in hearing and speech. Natalia's family selected a listening and spoken language approach for her. To achieve this goal the speech-language pathologist needed to plan and execute an appropriate auditory learning program. The first task for the SLP was to collaborate with an audiologist to ensure appropriate auditory access and then to determine Natalia's current functional auditory performance. It was important that Natalia's SLP have specific knowledge and competencies, including assessment of functional auditory performance, to be able to provide an effective intervention program for her. What should the SLP know about assessing listening skills?What instruments will best assess Natalia's listening skills? How should the SLP use the results of this assessment to develop an auditory learning program for Natalia?
SLPs often are required to provide services to children with a variety of hearing loss histories. Surveys have shown, however, that despite their academic and clinical preparation, many school-based SLPs feel unprepared to work with children with cochlear implants (Cosby, 2009). Research shows that audiologists and teachers of individuals with hearing loss feel similarly unprepared to work with children with CIs (Itzhak, Most, & Weisel, 2005; Luckhurst, 2008). Specifically, some SLPs reported that they received insufficient graduate training related to evaluation and treatment of children with CIs and have limited knowledge and skills in the assessment of children with CIs (Compton, Tucker, & Flynn, 2009; Houston & Perigoe, 2010; Wray & Flexer, 2010)—perhaps because children with CIs are a low-incidence population. It is important that SLPs acquire these skills if they are not comfortable working with this population or have had limited exposure to children with hearing loss.
Several ASHA guidelines, position statements, and technical reports outline the special areas of knowledge and skills necessary for SLPs and other professionals to optimize communicative and linguistic competence and related outcomes for children with hearing loss, including those with CIs. These resources delineate broad areas of expertise and clinical competencies that SLPs should have in working with children with hearing loss and assistive technologies used to facilitate listening and spoken language (AGBell, 2007; ASHA, 2004a, b)
Educational audiologists play an important role in school-based services, but they are not available in every school. It is critical for the SLP to collaborate with the child's clinical audiologist to understand the child's hearing technology and unique needs. Collaboration with the child's audiologist is imperative to setting realistic goals and providing appropriate intervention (ASHA, 2002).
In schools without access to educational audiologists, SLPs often serve as a key person in working with school-age children with CIs. They are required to conduct assessments that inform instruction and intervention, consistent with evidenced-based practice (EBP); manage the habilitative needs of children with CIs in collaboration with other professionals and parents; and promote efficient and effective outcomes (ASHA, 2010). Where should the SLP begin?
Assessment of Functional Listening Skills
We suggest that when working with a student with a CI, the SLP begin with an appropriate and comprehensive assessment of functional auditory skills [using measures such as the The Early Speech Perception Test (ESP; Moog & Gears, 1990) or the Auditory Perception Test for the Hearing Impaired (APT/HI-R; Allen, 2008)]. Next, the SLP should administer speech, vocabulary, and language measures. This major task requires the SLP to be knowledgeable about the development of listening skills and identifying auditory/linguistic milestones that might be demonstrated by the child in the diagnostic session (Houston & Caraway, 2010; Compton, Tucker, & Flynn, 2009; Cosby, 2009; Luckhurst, 2008).
The functional assessment first requires that the SLP partner with the student's audiologist to obtain information on the child's acoustic and phonemic access to sound. The availability of implant and hearing aid technology has placed additional emphasis on the development of listening skills. This technology offers increased potential for auditory access; its use has resulted in improved outcomes for children with profound hearing loss because this access provides the foundation for speech and language development (Moog & Geers, 2010). This technology requires SLPs to:
- Know how to examine and interpret an audiological profile.
- Be familiar with the technology of cochlear implants and/or hearing aids and how to troubleshoot.
- Attend to key background demographics of the child (e.g., degree of hearing loss, age at onset, etiology, the presence of additional disabilities, listening vs. chronological age) to assist in the selection of assessment protocols or instruments that will provide information on the child's listening skills using selected demographics of the child.
- Understand the continuum of auditory skill development.
- Select appropriate measures to assess listening skills in school-age children with CIs.
- Understand protocols and the type of information gleaned from various tests and assessment procedures to develop an appropriate auditory learning program.
- Work collaboratively with various professionals to obtain information on the child's auditory skill development (e.g., educational audiologist, parent, teacher, physician, cochlear implant team members).
Ultimately, to assess listening skills SLPs must be familiar with widely accepted frameworks of auditory skill development (e.g., those proposed by Caleffe-Schenck & Iler Kirk, 2004; Chute & Nevins, 2006; Erber, 1982; Estabrooks 2006; Tuohy, Brown, & Mercer-Moseley, 2005), which provide information about what the child should be hearing functionally across the continuum of listening skills. They also provide additional habilitative information that can guide assessment and assist in the development and implementation of an appropriate plan of intervention for auditory skill development.
Evaluating a child's listening skills is a crucial part of the assessment process and is essential in formulating functional listening goals. SLPs often arrive at an assessment session with strong knowledge and clinical diagnostic skills of general assessment protocols and techniques. However, improved technological device use by children with hearing loss requires modifications in assessment paradigms. An audiogram and a CI program may provide insufficient information to design an optimal auditory-learning program.
When assessing a child's functional auditory skills, the examiner should be familiar with how children "perceive, process, and produce" language (Allen, 2004). Appropriate assessment protocols or instruments provide information on the child's ability to perceive and process auditory messages, assess children at different levels of skill development, and demonstrate progress over time. And, as more children with hearing losses are being served in general education classrooms, it is also important to consider the auditory demands of the classroom and the auditory environment in which the student must function throughout the school day (see The Assessment of Mainstream Progress in Chute & Nevins, 2009). See Figure 1 [PDF].
Often, the child arrives at the diagnostic session with limited auditory skills (Cole & Flexer, 2007). Because very few formal tests are available to assess functional listening, it is critical to understand the developmental hierarchy of auditory skills (i.e., simple detection through open-set comprehension of spoken language; Erber, 1982) and obtain baseline information regarding discrete auditory skills across that functional continuum. For example, at the Clarke Schools for Hearing and Speech-Jacksonville, a child's location on the continuum of listening skills is determined by a variety of assessment protocols and tools, including the Early Speech Perception Test (ESP; Moog & Gears, 1990), the Auditory Perception Test for the Hearing Impaired (APT/HI-R; Allen, 2008), the Test of Auditory-Processing-3 (TAPS-3; Martin & Brownell, 2005), and the Auditory Processing Abilities Test (APAT; Ross-Swain & Long, 2004). No one test can describe adequately the scope of a child's functional auditory performance. A comprehensive assessment usually includes a variety of measures to assess a child's overall auditory, speech, and language skills during a specific point in time. However, these tests can provide valuable information about the functional auditory skills of children as young as 2 years.
The ESP obtains information about speech discrimination skills in children who are deaf and hard of hearing (DHH). Created for use with children ages 3–12 who have profound hearing loss and limited vocabulary and language skills, the ESP determines if the child has only very basic skills (e.g., pattern perception of a continuous and intermittent signal as in /ah/ vs. hophophop) or can identify monosyllabic, spondee, trochaic and/or multisyllabic words. The results place children in four speech perception categories: 1) no pattern perception; 2) pattern perception; 3) some word identification; and 4) consistent word identification. The test provides information about the listening and verbal (word approximations or vocabulary) development as the child progresses throughout intervention.
The APT/HI-R is based on the assumption that children acquire auditory perception abilities in a developmental and hierarchical manner, starting with simple detection through open-set comprehension of spoken language (Erber, 1982). This tool helps SLPs, aural habilitationists, auditory verbal therapists, and teachers evaluate the ability of a student who is DHH to decode spoken language and to design an individual auditory development program. The APT/HI-R measures functional speech perception capabilities in individuals ages 3 and up with profound to moderate hearing loss. The 30-minute test measures 16 different skill areas and may be used with the ESP to develop baseline information about the child's auditory functioning with discrete skills from detection to open-set language during initial and subsequent assessments. The results are reported as a profile (rather than a score) that provides a picture of where the student is functioning on an array of discrete auditory skills across the auditory continuum of listening/learning. Visual and auditory-only profiles are used to document progress following ongoing intervention.
The TAPS-3 is standardized on children with normal hearing and is used with children from ages 4 years through 13 years, 11 months. It assesses specific higher-level auditory perception skills (e.g., word discrimination, phonemic awareness, phonological blending, word/number and sentence memory, auditory comprehension, and reasoning). The four areas of focus are auditory attention, phonological skills, auditory memory, and auditory cohesion, skills that are necessary to function in a general education setting. Similar to the Assessment of Mainstream Progress protocol (AMP; Chute & Nevins, 2006), the test is used after open-set comprehension is achieved and may help determine the child's readiness to be successful in the general education setting. This test may also be used to track and monitor the child's auditory progress or regression in the mainstream setting.
The APAT uses a model based on a hierarchy of auditory processing skills that are basic to listening and processing spoken language. Developed for children ages 5 years to 12 years, 11 months, this test determines a child's specific auditory processing strengths and weaknesses. The results of 10 subtests (e.g., traditional evaluation such as auditory memory, processing of sentences and extended material/passages, phonemic processing, cued recall) quantify and define the severity of auditory processing disorders and can be used to document and monitor a child's improvement in auditory processing skills as a result of intervention.
Developing an Auditory Learning Program
These assessments provide baseline data of a child's auditory and speech production skills that can be used to document and monitor progress and to design and implement comprehensive auditory learning programs with appropriate targets. For example, the ESP (for a low verbal child) and the APT/HI-R (appropriate sections as described in the manual) can be used to gather baseline information for children who do not have open set comprehension and/or use of spoken language. The ESP and APT/HI-R can be used to track progress with intervention. The ESP measures basic skills and vocabulary and the APT/HI-R measures discrete auditory skills over the continuum of listening to open-set comprehension. The TAPS-3 can be used to determine success in regular education and to monitor auditory progress. The APAT assesses higher-level processing of typical language structures and can be used to assess the child's functioning in a mainstream setting.
An integrated approach using developmental techniques and corrective strategies will facilitate listening and spoken language. The performance expectations for a child who receives a CI will influence the type and intensity of a plan of intervention. In designing an auditory learning program, a clinician "must know…where the child is in order to know where to go" (Allen et al., 1999). All the assessment data should be analyzed and synthesized to formulate appropriate goals for intervention (Thibodeau,2009). Such information is necessary to reinforce learned skills, introduce new skills, and evaluate the functional auditory skills of the child as he or she progresses across the different domains of listening (detection through open-set comprehension and complex auditory skills). See Figure 2 [PDF].
Assessment results also guide the development of individual educational plans with specific target behaviors, determine what modifications the student might require in the general-education setting, develop progress-monitoring tools, complete third-party billing, and provide information to all professionals involved in the child's education.
Increasing Skills and Knowledge
Although a few programs focus on preparing SLPs to work with children with hearing loss, typical graduate programs for SLPs provide limited course work and experiences in working with children who use amplification or cochlear implants (Houston & Perigoe, 2010b). More studies are needed that assess SLPs' competencies, educational preparation to assess and treat children with hearing loss, and need to acquire knowledge and experience in working with children with CIs. This information will guide training programs to broaden their emphasis on preparing SLPs to work with school-age children with CIs.
SLPs interested in working with young children with hearing loss can increase their knowledge and clinical skills in various ways, including self-study, observation of competent clinicians, attendance at presentations and lectures, visits to sites that specialize in helping children with CIs learn to listen and speak, and participation in focus groups, which can serve as collaborative initiatives that allow professionals the opportunity to gain a deeper understanding about their skills, knowledge, and experiences about working with children with hearing losses.
Extensive training programs (e.g., Professional Preparation in Cochlear Implants) offer professionals the opportunity to retool and/or increase their clinical competency. Graduate training programs for SLPs that specialize in preparing professionals to use auditory-verbal techniques are developing across the country (see The Volta Review, summer 2010).
Advances in newborn hearing screening and hearing technology have resulted in greater opportunities for children with CIs to develop listening and spoken language skills.
However, children with hearing loss cannot capitalize on the access to sound and spoken language without professionals who are knowledgeable and skilled in assessing and developing listening and speaking skills (Robbins, 2009). School-based SLPs and audiologists working as a team will ensure that children with hearing loss make maximal use of technology to access the auditory signal. It is essential that clinicians, both SLPs and audiologists, providing services to children with CIs increase their knowledge and clinical competence in the assessment of auditory functional listening skills; use appropriate auditory perception tests to determine current functional auditory skills to develop auditory targets; and use this information to design an optimal management plan. Maximizing audition will drive listening, speaking, and learning opportunities that ensure the successful integration of children with CIs into mainstream education.
*Note: Natalia entered a general education first-grade class in 2008 and entered third grade in the fall.