With the advent of neonatal hearing screening and technological advances in cochlear implants, more children are being served in general education classrooms each year. As children are identified earlier and fit with amplification or a cochlear implant at an earlier age, they are more readily entering mainstream education and closing the gap in their performance relative to their peers with normal hearing.
This presents several challenges that must be addressed by both speech-language pathologists and audiologists who serve children with hearing impairments in the public schools. Three critical areas that can affect the success of a child with hearing impairment in the mainstream are: classroom placement and related challenges in that environment, technologies that allow access to auditory information, and combined efforts of the SLP and audiologist to serve children and their families and provide support for educational personnel. Professionals serving children with hearing loss in the schools can significantly affect these three areas and in doing so not only assist the child but also facilitate their own daily efforts to provide optimal intervention for those with hearing loss.
Classroom Placement and Related Challenges
When considering a child's educational placement, the most available options are usually the general education classroom, a special class, or a combination of the two. For placement in the general education classroom there are three aspects of preparedness to consider: child readiness, school readiness, and parent readiness. A child being assessed for general education placement should have age-appropriate or near age-appropriate language, speech, academic/reasoning, conversational, and social skills. For children who use cochlear implants, good auditory skills are also important. Placing a child in the general education classroom without sufficient skills to be successful puts academic achievement at risk. Every child should be monitored carefully to determine if the placement meets the goals established for that child.
Determining school readiness requires: 1) evaluation of the school's ability to provide an optimal listening environment; 2) administrative support for the child, teachers, SLPs, and additional support personnel; 3) collaborative planning time for those serving the child; and 4) professional development opportunities to learn about the ever-changing technology and intervention strategies. Finally, parents who seek general education classrooms for their child should view this placement as a beginning rather than an end, ensure that the individual educational program (IEP) is a well-written contract, and be prepared to act as an advocate, especially for the younger child.
Appropriate placement is critical relative to the two main academic challenges children with hearing impairment face in the classroom: English language development and literacy development. The specific challenges for language development include acquisition of spoken vocabulary and complex syntactic forms. Reasons that lexical and grammatical development may be at risk include limited use and/or lack of maintenance of assistive technology, parents who are unwilling or unable to serve as language models at home, presence of a home language other than English, and language-learning challenges beyond those associated with hearing loss. The SLP and/or audiologist can facilitate maximal use of assistive technology through implementing daily checks of the systems and offering teacher inservice. Addressing the home language issue will require an orientation to supporting parents in language development techniques using their native language.
The second major challenge for children with hearing loss in the schools is literacy development, which first entails learning to read and then reading with comprehension. In order to break the code, the child must have certain prerequisite skills that include the cognitive ability to process symbols, adequate audition to make use of phonetic cues, and sufficient language and experiences upon which new information can be interpreted.
Reading comprehension is dependent upon having a substantial vocabulary and knowledge of complex linguistic forms supported by a rich experiential base, developing the ability to comprehend figurative language through critical thinking, and implementing metacognitive strategies. To facilitate reading skills, a child needs a well-developed "schema," or experiential base. Children who develop a strong vocabulary will have increased access to learning additional vocabulary through reading because of their ability to learn new words in context. Comprehension of figurative language increases the child's ability to understand text. The ability to make inferences-to read between the lines-and to use metacognitive skills-to monitor understanding-will strengthen overall reading comprehension.
In order for children to access language, break the code for reading, and acquire comprehension skills, assistive technology that provides access to auditory information is critical. With increased access, a child will gain a greater fund of knowledge that will lead to stronger language competence and therefore improved educational outcomes. As more children enter mainstream education, there are several technological issues that must be considered in order for these students to make optimal progress. The audiologist and SLP working together as a team can facilitate access to auditory information through common knowledge of the goals and fitting/evaluation process.
Many of the considerations regarding technology in public education are related to legal mandates. The Individuals with Disabilities Education Improvement Act (IDEIA, 2004) mandates a "free and appropriate public education" in the "least restrictive environment" that is based on the IEP of the student.
In addition to these criteria for the student, IDEIA also provides for: 1) related services including audiology, parent counseling, and training; 2) assistive technology and assistive technology services; 3) proper functioning of amplification devices used in school; and 4) meeting the child's communication needs. Meeting these needs requires access to communication. Communication access is more than simply understanding the teacher and being understood, but also includes understanding peers and being understood, tracking conversations between multiple speakers, effectively participating in individual and group discussion, and social interactions.
An often neglected aspect of meeting a child's communication needs is the "ease" of communication, or the ability to feel comfortable with a communication partner in the classroom as well as in social situations. To state it simply, access to communication occurs when there is "shared meaning." In order for there to be access to communication throughout the educational environment, several requirements must be met. There must be simultaneous access to multiple communication partners. In addition to a high-fidelity signal that automatically adjusts to a variety of communication situations and environments, it must also be consistent and interference free. The instrumentation must be user friendly and cosmetically acceptable. Finally, it must be capable of coupling to a variety of technologies such as phones and computers.
To maintain this access, schools are faced with multiple challenges, including managing a variety of hearing instruments/CIs as well as hearing-assistance devices. This includes keeping abreast of current technology changes, validation techniques, and specific needs of special populations such as cochlear implant users. Training for general education teachers will also be important so that the technology can be maintained and function consistently without interference. Failure to address these challenges may result in reductions in speech perception that, in turn, can lead to reduced comprehension and academic performance. These difficulties may then lead to increased social difficulties and ultimately low self-esteem.
Appropriately fit assistive technology is a major component of access to communication because of its ability to reduce the deleterious effects of noise and reverberation. The process of getting assistive technology involves the following steps: audiological candidacy analysis, device considerations and selection, verification of fitting and performance, orientation and training, validation through objective and subjective measures, and documentation in the IEP. Once these steps are completed, plans for technology maintenance are needed. The IEP needs to contain a statement describing who does the monitoring and how often it is checked as well as how parents are notified of any equipment malfunctions.
A Team Approach to Services
The SLP and audiologist ideally work as a team to serve children with hearing loss in the schools. They may be referred to as aural habilitation specialists because they are competent in training children with hearing loss and their families to maximize auditory communication. The responsibilities and roles of these professionals include communicating with parents, administrators, and teachers; presenting inservices; facilitating speech-language development; evaluating hearing; fitting and maintaining technology; managing noise; and offering parental support.
The services provided by the SLP, educational audiologist, and classroom teacher are critical to the child's success, but of reduced value if conducted in isolation. It is only when the professionals are in regular communication regarding their (re)habilitation efforts that the child receives maximal reinforcement.
This regular contact is facilitated by cross training among professionals so that there is mutual understanding of respective roles and approaches. One example of such cross training from the Pediatric Aural Habilitation Program at the University of Texas at Dallas is included in the Training Objectives sidebar. Professionals who serve children with hearing loss must have common knowledge about communication, hearing loss, technology, families, and educational issues. Then each profession is trained in specific skill areas, shown in the Training Objectives sidebar, to provide necessary services to children with hearing loss.
The SLP and audiologist must include the general education classroom teacher as part of the team, particularly as they work together to maximize the use of the assistive technology. The primary technology to facilitate auditory perception in the classroom is the use of an FM system to improve the signal-to-noise ratio. Audiologists must convey beneficial features of new FM technology such as directionality of transmitters and automatic frequency synchronization to easily change channels for individually-worn FM systems. Being able to change channels easily facilitates FM use in situations where classes change frequently such as in secondary schools or even in preschools where instructional centers are offered in different rooms. Use of ear-level FM technology may reduce complexity for the team, particularly when the school district purchases the complete ear-level FM receiver for each child. Although soundfield FM systems also reduce complexity, this discussion is focused on individually fit FM systems.
A complete individual system provided by the school could be called a basic FM system, in contrast to one that interfaces with a student's personal hearing aids. In programs with basic FM systems, a child would remove his personal aids when he arrives at school and put on the FM arrangement provided by the school for use during the day. The school typically provides the earmolds and batteries to use with the basic FM system. At the end of the school day, the basic FM system is returned to the storage cabinet in the classroom and the personal aid is used at home.
A basic, ear-level FM receiver may consist of a single unit or a three-component system. A single-unit FM system has the FM amplifier and receiver contained within the behind-the-ear case. A three-component system includes an FM amplifier (also called a hearing aid), and an FM receiver with an FM audio shoe connecting them, see figure 1 (PDF format). The terminology, FM amplifier, is used to avoid possible misunderstandings by school administrators that "personal hearing aids" have been purchased for students. Advantages and disadvantages of using basic, ear-level FM systems are provided in the Advantages and Disadvantages sidebar.
Perhaps the most critical time to function as a team for teachers, SLPs, and audiologists occurs at the beginning of each new school year. Because audiologists are typically serving students in several schools, the teacher and SLP of the local school can help gather vital information to facilitate FM setup. Items of particular assistance include the school calendar, daily bell schedule, map, teachers' conference periods, e-mail addresses of those working with FM equipment (e.g., teachers, aides, interpreters), class lists, and students' schedules. Based on the class/schedule information and the location of classes, the number of transmitters, FM systems, and actual channels to be used can be assigned. The audiologist develops an "FM Master Plan" for each school that includes channel assignments by class and time of day. Sharing the plan with teachers and SLPs will allow them to assist with appropriate channel use and troubleshooting accidental interference.
Equipment verification, physically and electroacoustically, is another major effort in maximizing the benefit of FM systems for each student that can be facilitated by a team effort. Audiologists may develop handouts for daily checks, conduct inservice demonstrations prior to the start of school, and/or provide cell phone numbers for quick accessibility during the start- up for the new school year. SLPs may join audiologists in giving presentations in classrooms to the students regarding FM use. References to online resources for useful audio demonstrations and forms are provided in the Resources sidebar.
Having students record their own serial numbers on inventory forms, when capable, and discussing the cost of the FM system in terms of equivalency to popular items (e.g., one FM amplifier and receiver = 3 MP3 players) can help to instill responsibility for the equipment they are using. Several electroacoustic tests may be done in the initial programming of the equipment to ensure the child is receiving an optimal FM advantage. As recommended in the ASHA (1999) guidelines, the students ideally hear the teacher's voice about 10 dB above the environmental signal.
The final type of verification that can be facilitated by the teacher and SLP is behavioral evaluation with the FM system in a sound-treated booth. The recommendations in the ASHA (1999) guidelines are to measure speech recognition in quiet and noise, with and without the FM system. Measurement of pure-tone thresholds is not recommended because of the difficulty in placing the FM transmitter in the soundfield to simulate the arrangement in the classroom. The teacher and SLP can be particularly helpful in arranging to send the FM equipment with the child for the evaluation and providing information regarding language abilities so that appropriate test stimuli can be used.
In summary, the child with hearing loss is optimally served by an educational team that has specialized training in aural habilitation. The professionals serving the child with hearing loss should be in frequent communication and working toward common goals that include maximal use of technology to access the auditory signal. Improvements in technology have led to opportunities to maximize reception of acoustic information in the noisy classroom through ear-level FM receivers. Verification may include daily checks, electroacoustic measures, or behavioral evaluation. Teachers and SLPs are key to successful use of technology to maximize language and literacy development. They can train and then reinforce the child for identifying equipment malfunctions. They are most attuned to each child's functioning and likely to notice changes in responses, attention, and fatigue that may signal an equipment malfunction.
Most importantly, the team can provide immense psychological support for the child in the school setting. Excitement regarding success with technology can be generated among peers through acknowledgment by teachers, SLPs, and audiologists of students' consistent use of FM systems. Programs that recognize success in a tangible way can generate positive peer support for technology. Students may like to gain recognition via stickers on their systems, putting charms on the earhooks, or choosing colors of earmolds. Such support systems are developed and maintained through recognition of the mutual contributions and frequent communication among the teacher, SLP, and audiologist serving the child with hearing loss.
Portions of this paper were presented at the 2004 ASHA Convention. The contributions of Mary Ellen Nevins for that presentation and portions of this paper are gratefully acknowledged. The insights offered by teachers, audiologists, and SLPs from Dallas and Plano Independent School Districts are most appreciated. FM manufacturers including Phonic Ear and Phonak generously provided FM equipment for trials to facilitate the development of many of the concepts presented in this paper.