ROUGH EDITED COPY

UTAH STATE UNIVERSITY-CASEY JUDD

EHDI-JONES
KNOWING IF TECHNOLOGY IS DOING WHAT IT NEEDS TO DO
MARCH 10, 2015
9:10 A.M. ET

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			(Writer standing by.)
>> FEMALE SPEAKER:  Okay, everybody, I think it's exactly 10:10, so I'm going to start.  Shelley gave me a nice, good introduction.  She sort of gave you my idea, which is that we really need to know how kids hear.  Can I just ask, how many people in the room are audiologists?  Speech language pathologists?  Parents of children with hearing loss?  Any early intervention providers?  EHDI administrators?  What did I leave out?  
>> SPEAKER: (Off mic.) 
>> FEMALE SPEAKER:  Okay, good.  I'm going to give you all my prejudices today.  You know, the reason we fit technology on children is so that we can, I mean, we're not fitting technology just to fit technology, we're fitting technology so that kids can learn to listen and talk.  That's the reason we're doing it.  So, the goal of technology is to provide sufficient sound so that the child can develop an auditory brain, can hear and learn language, can build literacy skills and can develop social skills.  I need water.  Could somebody, do we have a helper in the back?  Thank you very much.  So, we're not, technology is not the goal in itself.  The goal is language learning.  So, what does it take for a child to be successful?  The better you hear, the better you learn.  We know that.  So, we want early identification, and then we want early and appropriately fit technology.  It's not enough just to stick it on the kid's head.  We also need to know, thank you very much.  It's good to have friends in the audience.  We need to know that the technology is doing what we want it to do.  
We need therapy, because by itself, fitting the technology is not enough, the kids have to have therapy, and for them to learn to use their hearing, it has to be auditory‑based therapy.  We need to teach the kids to rely on listening to learn.  They need family support, they need a language‑rich environment, people need to be talk, talk, talk, talk, talking to them all the time.  Just putting hearing aids on and nobody having a conversation with them is not going to have these kids develop auditory skills.  They need opportunities to learn.  They need to be in a place where there are lots of people who are giving them a lot of stimulation, brain stimulation, language stimulation, and they need to be in educational programs that are willing to deal with the fact that there's a hearing‑impaired child and they need to make changes.  The goals of technology are, obviously, first to reduce sensory deprivation, to provide access sufficient to learn, to improve auditory access to language so that they can learn language through their ears on the way to the brain, as my friend would say, to maximize the use of residual hearing so that every, I mean, one of my old students said to me, every time I think about you, I think about your saying, every decibel counts, and it does.  Every decibel is important. 
It's not okay to hear just okay, it's only okay to hear great.  We want to be able to make sure that they have enough hearing for academic learning and to facilitate the ability to understand information that's not talked to them directly.  If we have to teach children everything, we need to be standing in front of them and providing them direct information.  We know that about 90 percent of what kids learn, they learn incidentally, by overhearing conversation, and we need to be sure that our kids have enough hearing so they can do that.  We want to facilitate their ability to socialize using hearing, because the more language a kid has, the easier it is for them to socialize.  We want to be sure that they have safety warnings using hearing aids, and we want to be sure they're comfortable.  So, we have a few basic assumptions about amplification; appropriate amplification is the most important rehabilitative tool, so it's our job to make sure it works.  We know that while amplification is critical, it's not enough.  It needs to be part of an entire program that includes therapy and parent support and educational support, and we, and the audiology part is one wing of that. 
We know that the amplification choice is dependent on the child, on the communication environment with which the child exists, and on any other issues around the child.  If the child is in an environment in which people are expecting listening and spoken language, every decibel counts, and we need to be sure the child's hearing it.  We know that standard hearing aids work well for children with mild through moderately severe hearing loss, and we know that cochlear implants work well for children with severe and profound hearing loss.  If a child is not doing well with a hearing aid, we need to think about moving them to a cochlear implant.  Time is of the essence for listening.  We know also that an FM system will work for everybody who has any kind of auditory function disorder.  It should be a basic part of fitting technology.  We should include it in every technology fitting that we do.  It's not let's wait and see if he fails, we need to have an FM available for everybody.
So, first, you have to hear well.  Hearing is a first order event.  It is critical for the development of spoken communication and language learning and also for literacy skills.  Anytime we think the word hearing, we need to think auditory brain development.  Acoustic accessibility of intelligible speech is the goal.  It's not just get something in, it's get it in so it is completely clear.  We want to know that the signal to noise ratio situation is controlled.  We want them to be hearing well enough so that they can learn.  We want to know that our early intervention centers and our classrooms are taking into account that there are children in them who need to hear, so we want them not to be noisy, we want them to do all the things that we need to do to reduce noise in the classroom, and I can't talk about that in a 30‑minute talk.  So, here, we have a picture of sort of what has to happen.  If you have appropriately‑fit technology and an enriched auditory exposure, you're going to have good brain development.  If you do not have appropriately‑fit technology, no matter how good the auditory brain development is, the auditory exposure is, you won't have good auditory brain development.  You can have the best technology, if you don't have auditory exposure, you won't have auditory brain development.  It is critical that we have all the pieces working.  
So, good auditory access requires that a child hear, throughout the frequency range, that they hear at the top of the speech banana, which I call the string bean.  We want them to hear at the top, because I'll show you why in a little bit.  They need to be able to hear normal conversation, but they need to be able to hear soft conversation, because they need to overhear conversation around them, and they need to be able to hear in noise because the world is a noisy place.  They need to also be able to hear every waking hour.  So, what does a child need?  They need to hear throughout the frequency range.  6,000 and 8,000 hertz is critical.  I mean, every time I say this, hearing aid people say but the hearing aids don't go there.  Isn't that unfortunate?  Because if you don't hear that, you're going to miss possession, non‑salient morphines.  We think that's okay?  No, it's not.  They need to hear high frequencies, soft speech, and more importantly, they need to hear the kids who are making comments in the classroom, they need to be able to hear that kid when the teacher asks a question.  It's not just the right answer you need to hear, you need to hear all the wrong answers, because that helps you understand.  
They did a study a number of years back and showed that 40 percent of kids were not appropriately fit with their hearing aids.  How many people find that a scary statistic?  I mean, it terrifies me, just terrifies me, and these kids are all under‑amplified, and I'm going to show you some things.  So, our goal is to have them hear at 20 dB throughout the frequency range.  So, what do kids need to hear?  Okay, something happened when this got transferred, and there's something going on in the computer system in this hotel, so the phonemes are not, I mean, the phonemic description is not a rectangle, but that's how it came out, but so these are the frequencies, the first format and the second format for these vowels, and you can see that for vowels, except for E, they're all low frequency.  E is at 3200, which is a mid‑high frequency, but let's look at the consonants.  Consonants have energy in four format areas; low, low mid, mid‑high and high.  I want you to particularly look at how many formats have energy at 4,000 hertz and above.  Half of our consonants have energy in the high frequencies.  Is it all right if the kids don't hear that?  Not if you're planning on having them use listening and spoken language.
So, if something is wrong, suspect the technology first.  Most likely, that's the problem.  Is the child hearing well enough with the technology?  You won't know that if you don't test.  Is the child hearing high frequencies?  Is the child wearing the technology consistently?  That means is the child wearing the technology all day long.  If a child uses technology 4 hours a day, it will take that child 6 years to hear what a typical hearing child hears in 1 year.  I think that's a very important piece of information that we need to say to parents, because it's only, when they understand that piece of information, they're more likely to keep technology on their kid's heads all day long.  So, we also need to know whether a family has appropriate expectations for their child.  Are they taking their child seriously as far as listening is concerned?  Are they talk, talk, talking?  Are they exposing the child to all kinds of language?  Are they reading a million books?  Are they singing?  Are they providing all the auditory stimulation that a child needs?  Do the clinicians working with the child have appropriate expectations for the child?  Do they know what they want?  This little boy is now an ENT resident with two cochlear implants.  
So, what are the test protocols we need to have?  What is it that we need to do to be sure that our kids have accessible hearing?  We need to have evidence in a sound booth that we've got thresholds that are where we want them to be, and we need to have speech perception tests that indicate that the child is hearing what we need them to hear at normal and soft conversation and quiet and in competing noise.  We need to know what the parents are observing.  What does your child hear, and more importantly, what does your child miss in daily living, and we need to know that from the therapist and the teachers working with the child, and if you're lucky enough to have a LENA system that you can use on a baby to help you understand how much sound a child is receiving, that would be terrific.  So, here is a list of what kind of testing I think you need to do.  Shelley spoke before about using real ear, and real ear is a critical part of testing, but it's not enough.  It doesn't tell us what's reaching the brain.  It tells us what's reaching the TM.  Real ear only tells you what's going into the ear, and you can get real ear on a corpse as long as they have a tympanic membrane, but you cannot get information from real ear about how the child understands speech.
So, every child needs aided thresholds, right technology and left technology alone, because as she said, if you test with two ears together, one of them could not be on at all and you would never know.  You need to know, you need speech perception testing at normal conversation for the right ear, the left ear and binaurally, and you need it binaurally so that you can be sure that you know if using the two together is causing some distortion.  You need at least to do speech perception for soft conversation binaurally and in noise, and if you have time, do them separate ears, but time is always an issue, but it's information you actually really want.  Just in case you don't believe you can do speech perception in all of those test situations, this is from a study that I did a number of years ago, which shows that even 3‑year‑old's can do speech perception in noise and get scores of 88 percent of better, so don't tell me you can't do this test, because you can.  So, the reason we're doing all of this testing is so we have a real picture of how a child is hearing.  We want to get a better picture, a more realistic picture of how they're hearing, what they're hearing and what they're not hearing, because if we have that information, we can make good decisions about whether we need to change the technology, whether we need to, what we need to do about classroom management, what do they need in the classroom, what do they need in therapy.  We can't make those decisions if we don't have the data.
We need to know exactly how they hear.  Are they hearing well enough?  Do we need to change the settings on the hearing aid?  Do we need to try a different hearing aid?  Should we move on to therapy?  Should we move on to a cochlear implant?  They're hearing well enough with their technology, but their speech perception's not good, we need to say to the therapist, okay, now you have to fix the therapy.  So, if we don't test, we don't know what to tell families, and it has to get better.  So, here is the audiology fruit that we all know and love.  If you hear at the bottom of the banana, at the C level, you're going to hear 10 percent of what you need to hear.  If you hear at the top of the speech banana, you're going to hear 90 percent.  If you hear at the middle here, you're going to hear 50 percent.  So, the only thing that's acceptable, from my point of view, is to be hearing at the top of the speech banana, which is why I'm changing from a fruit to a vegetable and going to the string bean.  You really need to be hearing at the top of the speech banana.  That's our goal.  
When the speech banana was originally started, people were not thinking that this was, that you needed to hear somewhere in the speech banana.  The speech banana was designed to show where speech information is, but the only way you hear, you can only hear the things that are under your aided thresholds, so if your aided thresholds are at the top of the speech banana, you're going to hear all the phonemes, if they're in the middle, you're going to miss a lot, and that's not acceptable.  So, here's an audiogram.  This child has a moderately severe hearing loss, and the R's are the right hearing aids, L is the left, F is how he's hearing with his FM  This child has great auditory access.  I'm not worried about access for this child.  He's hearing what he needs to hear, but when I, there's another slide that I took out because of time here, but if his speech perception wasn't good there, then I would know he needed, then I would say to the therapist, he's not understanding enough with his hearing aids, we've provided enough access, now he needs some therapy.  So, here's a kid who's hearing within the speech banana.  This kid's got a severe to profound hearing loss, borderline profound, the right hearing aid, he's hearing middle of the speech banana, the left hearing aid, the low end of the speech banana.  That child doesn't have enough auditory access.  If I can't fix how he's hearing with his hearing aids, it's time for me to say let's consider a cochlear implant, because he's not at the string bean, and you can see from his speech perception, this kid is doing, with the right hearing aid, where he's hearing over there, he's got 76 percent, with the left hearing aid, he's got 68 percent.  Is that good enough? 
As Shelley said, my line is if it's not good enough on a math test, it's not good enough on a speech perception test.  That is not enough hearing, and look what he's hearing for soft speech, and why is he hearing that badly for soft speech?  Soft speech is 30 to 35 decibels.  If his thresholds are at 40, how can he hear soft speech?  It's below what he hears.  In his right here, his thresholds are at 30, so he's hearing very softly.  What is he going to get from that?  We need to know.  We have to fix it.  Look what happens for speech in noise; 48 percent.  How is that kid possibly going to manage in a classroom?  Here's another kid.  This kid is going to be a little confusing to some, to parents, maybe, because you call him and he turns around because he's hearing at the top of the speech banana for low frequencies, but look what's happening for the mid's and high's.  He's not going to hear well.  He's not going to learn language if he hears that way  So, why do we test functional gain?  Real ear is very important.  I am not saying we shouldn't be doing real ear testing, but it doesn't tell us what the child hears.  It doesn't tell us what's reaching the auditory brain, and if we don't know what's reaching the auditory brain, we don't know anything.  We just don't have any information that's useful for this child. 
So, we need to know, first of all, does the child attend to sound, does the child tune in, is the child paying attention, does the child use auditory information, is he responding to auditory signals, but we also need to know whether the signal is clear or distorted.  Maybe when a child has, excuse the technical word, puky speech perception, it's because there's distortion in the system.  We need to know that and we need to check it.  So, my goal is aided thresholds, a 20 to 25 throughout the frequency range, and speech perception that is excellent at normal and soft levels in quiet and in competing noise.  Let me ask a question.  Is it okay, does a deaf child need to hear as well as a hearing child in a mainstream classroom?  Is there anybody who thinks the answer to that is no?  Of course they do.  So, we need to know, if we're expecting them to learn by listening in a mainstream classroom, we need to be sure that they can hear there, so we need to know they have good speech perception at normal and soft conversation and quiet and in competing noise.  I think it's also important to understand what good speech perception is.  I did a survey a number of years back, and I was amazed at how many people thought that for a deaf child, 40 to 50 percent was excellent speech perception. 
I have a news flash; it isn't.  Excellent for a child with a hearing loss, who's trying to learn using audition, is exactly the same as excellent for a typical hearing child who's trying to learn using audition.  Excellent is 90 to 100 percent, good is 80 to 89 percent, fair is 70 to 79 percent, and speech perception below 70 percent is poor, and that's the end of it.  That's what it is, it's poor, and so when an audiologist writes a report on what is good speech perception, please write, please use appropriate descriptions here, because otherwise, nobody knows they have to fix it.  I mean, I've had so many people say, I mean, parents are working so hard, I don't want to tell them this kid's speech perception is poor.  Well, if you don't tell them, they can't do anything to fix it.  So, we need to be honest.  How do you know when it's time to move to a cochlear implant?  Evidence that supports moving from hearing aids to cochlear implants is the child isn't hearing well enough.  They're not hearing at the top of the speech banana and they don't understand speech and language.  Things that are not important in making the decision are I like my hearing aids.  Those cochlear implants are too big, I don't like what they look like, or the child is making progress in language and learning, but is the progress fast enough?  And will they be able to maintain it?  We know as kids get older, maintaining progress becomes more difficult, so we need to be sure that they have access when they're trying to maintain progress.  So, yes, it's irrelevant that I like my hearing aids.  
The only thing that's relevant is I hear well enough with my hearing aids.  So, I refer kids for cochlear implants if they're not hearing at the string bean, if they're not hearing high frequencies, if they're dependent on an FM in order to be comfortable functioning, if they're making slow auditory progress, slow language process, slow academic progress, and we need to remember that there are critical periods for developing the auditory brain, and we want to be sure that we're providing access early enough.  Most children with hearing loss we know are educated in the mainstream setting.  It's more than 80 percent depending on where you are living.  Those children rely on audition in order to learn.  We also know that it's essential for them to be able to hear soft speech and to hear in noise if they're going to function.  They need to be able to hear high frequencies.  High frequencies are critical, and they need to be able to hear soft speech.  Typically, children who are borderline candidates for cochlear implants, you know, they get CI's when they start to struggle in school.  I'm saying we should try to think about not waiting for them to struggle, because catch‑up is hard.  Questions?  I did that fast.  That was pretty good.  
>> SPEAKER: (Off mic.) 
>> FEMALE SPEAKER:  What strategies do I have for getting good access in the high frequencies for hearing aids?  The first, there are two strategies, pick hearing aids that have extended high frequency range and Libby horn ear mold tubing.  They start off narrow and it gets wider, so it looks like a horn, and it provides more high frequency access.  If that's not enough, move on.  
>> SPEAKER: (Off mic.) 
>> FEMALE SPEAKER:  What do I think about moving up in power as opposed to moving to a CI?  You move to a CI when you've done all those other things.  You go through, I mean, if you have a child with a severe hearing loss who's wearing a mini aid with an open fit, you don't say, okay, you need a cochlear implant, you say let's start off by closing off the ear mold, then let's go to a more powerful hearing aid.  A cochlear implant is the step after there's no more hearing aid that works.  Go ahead.  
>> SPEAKER: (Off mic.) 
>> FEMALE SPEAKER:  Nobody seems to.  
>> SPEAKER: (Off mic.) 
>> FEMALE SPEAKER:  What's effective use of an FM system?  Um, in academic, in an academic learning setting, you have to have it on full‑time.  There's absolutely nothing to debate about that, and there has to be a pass mic, and the school has to be good about a pass mic so that any kid who has a comment has to talk into it, and if the kid is not going to do that, the teacher has to repeat.  I think that I give kids, I let kids have, I mean, you go to the playground, you don't need an FM, you go to lunch, you might want an FM because the cafeteria is an absolutely awful place, so give the FM to the kid across the table, but, I mean, I think you play out the situations.  You don't want to use an FM full‑time, but you want, with an infant, I do use an FM full‑time, because, you know, I'm just sort of in, in, in at that moment, but as kids get bigger, I think I use it for critical listening moments and then not all the time.  Do you agree?  
>> FEMALE SPEAKER:  I just want to add to specify of use out of school time, so that in the car, there's so many situations, see, our job is to get auditory information to that brain, and that information occurs outside of school in critical social contexts, so we want to make sure that's available, but I agree with Jane, not 100 percent of the time.  Many families will use 50 to 65 percent of the time with various people wearing the FM for the purpose of growing auditory information in the brain. 
>> FEMALE SPEAKER:  I mean, I do use the FM for things like sports.  I mean, I'll have the coach wear the FM and the hearing impaired kid has a real advantage.  He heard stuff he wasn't supposed to hear.  You know, there are a lot of situations.  Anybody else?  Let me just say for the parents in the room, if your audiologist is not providing this information to you, please ask your audiologist to do it.  I mean, say I need to know this so I can plan for my child.  Anybody else?  Thank you very much.  
(Applause.)

This is being provided in a rough-draft format. Communication Access Realtime Translation(CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.