CHOOSING HOME SCHOOL

So many of you are probably thinking why did we choose a state funded homeschooling program rather than a traditional homeschooling program?  Others are probably answering this question by saying that cost was surely the deciding point. COST had nothing to do with it.  Let me teach you something that many home schoolers probably are not aware of and likely do not need to worry about.


When you home school your children, YOU are responsible for their educational growth. At no point will the public system ever be required to be responsible for their educational growth.  Not even when the day comes that you are no longer able to home school your child because of work or other demands.  So what happens when that day comes?  You take your child to your district office and they administer a test for the child to enter their school.  If at that time the child is 12 years old and testing at the 2nd grade level instead of the 6th grade level, they will enter school as a 12 year old in 2nd grade.  (So if you have been in our shoes at any point, you probably already know where I am going with this.) For most families this is no problem, because if there is nothing wrong with the child, they will soak in what ever you are teaching them better than they would in a public system.  However, for a child with disabilities, it takes lots of effort and/or different teaching styles to learn.  If they are not taught for their needs then very likely they are going to test below level for their age.  So despite the fact that you may have started to home school them when they were already behind, they will still enter school at what ever grade they test in at.  Do you see the danger of traditional homeschooling for children with learning disabilities?  


In the state system the parent is the primary teacher for the child, though they are to assigned a teacher.  The teachers are only as involved as the parent would like them to be.  The state is still responsible for the child's growth and it is just as if the child were attending a public school. Children are not required to test into their grade if they ever return to their traditional District.  


The thought of homeschooling without the state program was scary for us.  We wanted to make sure that we were prepared for any event.  If  I ever had to go back to work or if our family experienced a difficulty of any kind, then our kids would take the loss.  We did not want to risk our children ever having to test into school and land in a grade not appropriate for their age. It was not worth it to us to take the gamble.

WHERE WE STAND

It has now been nearly 6 months since my last post and there has been some dramatic changes in our family life.  I have been feeling for a long time that I need to stop my posts which review the Book 'Teaching Mathematics to Deaf Children' and resume at a later time.  I feel that my energy will be best spent, on your behalf, if I focus my energy for a while on my experiences in dealing with the school system for my children.  These posts are going to be beneficial and quite helpful for any parent of a child with disabilities of any kind; Autism, ADHD, Dyslexia, Hearing impairment, Developmental Apraxia of Speech or Childhood Apraxia of Speech, Cerebral Palsy, etc, etc, etc. . .


So, as I said, and as many of you have probably noticed, it has been nearly 6 months since my last post.  WHY? Well quite simply I had the opportunity to put my children in a state funded homeschooling program and we took the plunge with both of my school aged children.  It takes quite the energy, organization, and time.  Though, I will tell you, it was the best decision we have ever made for our children.

CONCLUSIONS: COUNTING AND SIMPLE MATH

Research shows:


1) Hearing Impaired preschoolers are just as competent at some of the informal mathematical tasks as hearing preschoolers


2) When presented spatially, hearing impaired preschoolers are actually better than the hearing peers in presenting the right number of objects in an array


3) Teachers of Hearing Impaired preschoolers need to give them more opportunities to practice counting than would normally be offered to hearing peers.


4) It is very likely that Hearing impaired children start to fall behind simply from a lack of experience in counting. 


5) Current work on teaching Hearing Impaired children focuses on what informal mathematical methods hearing children invent and if the hearing impaired can do the same rather than on what informal mathematical methods the hearing impaired invent 


(recap of chapter 2; Nunes)

SIMPLE ADDITION; ADDING ON USING SIGN LANGUAGE

When learning simple addition, typical hearing children use their fingers in order to facilitate 'adding on'.  Say we have the problem 5 + 4, the hearing child will put up four fingers to help them add on from 5 to get their answer of nine.  However, a hearing impaired child being taught in sign language, is left at a disadvantage.  They use their hands to 'say' their numbers and therefore do not have fingers to count with.  In observing these children, Groen and Resnick found that some of these children 'invented' their own method of 'adding on' using sign language.  In the same problem 5 + 4 the child would start with a signed 5 on one hand and the sign for 4 on the other hand.  The hand with 5 would increase in increments of 1 while the hand with the 4 signed on it would decrease by increments of 1, until the hand that originally displayed a 4 signed a 0; then the child would know he had his answer on the hand that once displayed 5.

While my children (and many other hearing impaired children) do not use sign language, I felt I needed to document this observation in this blog, because methods for teaching hearing impaired children are not well known or researched.  My intentions of this section of the blog is to bring to light methods that work in teaching math to the hearing impaired children; in order to make education easier for them and help those who teach them know how to help them.

(called the signed algorithm found on page 41 of Teaching Mathematics to Deaf Children by Nunes)

VISUAL COUNTING - WHAT WORKS

I feel that it is very appropriate at this time to include the observations I have made with teaching counting to my children. However, as you read this, keep in mind that our children did not have hearing aids in their first years of school.  So while they have only mild impairments, they will not have the same outcome as other mildly impaired children who had hearing aids.  You may also consider that many severely/profoundly deaf children when aided will have hearing scores measuring on the low side of mild.  As a result, I believe that it is highly likely, my children's abilities in school reflect this population.

Alex was really our 'guinea pig'.  We sent him to school his first year of kindergarten and just expected that he was going to learn.  What was I thinking?!  So at the end of his first year of kindergarten he was counting to 3, despite being in the classroom counting to 100 with his peers everyday from day one til the end.  He was held back; I worked with him diligently over the summer and he was counting to 4 at the beginning of his second year of kindergarten.  At the end of that year, he was counting solidly to 9. I had begun to try to figure out better methods of teaching him how to count and found the most effective way was to have a number chart in front of him and have him count while looking at the numbers in front of him.  At the end of first grade he was counting to 29.  But he was saying fiveteen for fifteen.  As he started 2nd grade, he had a new teacher who required him to say 'fifteen', despite his speech impairment.  This was enough of a change to make his emerging abilities fall apart.  The counting string was no longer natural for him; he had to  think about what he was saying and began making mistakes at 13.  It should also be noted, because of the change in pronunciation, he was now saying 'itee' for 13,15,16.  So many times he would be on 13 and then jump to 17 OR 16 and go back to 14.  The US Department of Education Office of SPED states on their website, studentprogress.org that mistakes in pronunciation due to a speech impairment should be accepted.

Diego is a different story.  Much of what I needed to know I learned through Alex, so with Diego I started to count with him a year before he started kindergarten.  We started in the little preschool books which had a set of objects to count and then a set of lines to write that number on several times. We went up to 15 in those books, then I started to make worksheets with objects to be counted on them starting at 15 and each week adding more objects to the amount, to progressively work him up to 30.  He was counting up to 20 then I had Levi and stopped for about 8 weeks.  He dropped down to 14, and it took him about 2 months to recoup the numbers back up to 20 again.  So he started school counting to 20.  When he started school, I kept counting with him for the first few months, but when we put our house up for sale, I had to keep teaching supplies hidden and I could not maintain consistency (because they were not out to remind me).  With only the help he was receiving from daily counting as a class in school, he was only counting to 14 again at Christmas break.

I have found the most important tools to help my children have been:

1) The use of personally created worksheets that gradually increase the demand of counting

2) Using a 100's chart to have the children point to each number as they count

3) Counting along with them, but only saying the numbers that they miss.  I found it very important for me to anticipate the numbers I knew they would miss, so that there was no breakdown in continuity.  Eventually they pick up the numbers that you are saying for them, which extends their counting ability.
4) Please note, that corrections of pronunciation should not be made unless you know the child is capable of pronouncing it better.  They will self correct their pronunciations as they become more aware of the counting string.  If not, you can always correct the pronunciation (if it bothers you) once there skills are nearly mastered.

5) Daily practice with attention to detail is a requirement.

LEARNING STYLES OF HEARING IMPAIRED VS HEARING INDIVIDUALS

Researchers were interested to know if Hearing Impaired individuals tend to have poor number skills from the beginning and if not then when the break down occurred.  What they found was that young Hearing Impaired children actually had stronger number skills than their hearing peers, but as it is expected that children develop their counting skills, the hearing impaired children quickly drop behind.


Research has shown that Hearing Impaired (HI) individuals and Hearing individuals have different learning styles.    The HI population code information visually, whereas hearing individuals code information phonologically (or sound based).  These two learning styles have different uses.  Visual memory is useful for recalling location and phonological memory is good for recalling order or serial recall.  In addition to this studies have indicated that HI children have the same ability as hearing children to recall items, but if there is a specific order the items must be recalled in (serial recall), then HI children would perform worse than their hearing peers. 


Counting is by far the most difficult task that a hearing impaired child needs to accomplish.   If we take the skill of counting and classify it by these learning styles, it is obviously a task of serial recall of phonological items; in order to count you must recall the number words in a fixed order.  So the task of counting is more difficult for HI children than the hearing, regardless of if it is represented visually or orally, because it requires serial recall.  The fact that it is orally based just complicates things further.


 Not all languages are equal when it comes to learning to count.  Japanese and Chinese are among the easiest languages to learn to count in.  Counting in English requires memorization of the numbers 1-20 and then applying  the use of counting rules after that.  It was determined that when a child is able to count to 60, they are likely able to count to 99.  So a solid counter would be one who is able to count to 60.  In 1998 Nunes and Moreno found that HI children in 2nd and 3rd grade were still not able to count to 60, where as hearing children were able to count to 60 early in their 1st grade year if not sooner.  They also found that many HI 4th graders were still unable to count to 60.  The patterns of mistakes that HI children seemed to make were related to phonological confusion.  For example: 15, 16, 17, 18, 81, 82, etc., which error is not found in hearing children.


It was determined that it is very likely that hearing impaired children start to fall behind simply because they lack sufficient experience counting (pg 48).


(This information can be found on pages  25-30 & 48 of Teaching Mathematics to deaf Children by Nunes)

MATH PERFORMANCE OF HEARING IMPAIRED CHILDREN

While I am seeking knowledge of appropriate methods to teach hearing impaired children, I believe it is important to note characteristics of educational performance in these children, so we can understand the norm. So far in my reading, I have learned the following:

• The average hearing impaired 10 year old performs 2 years behind his/her grade level
• The average 15 year old performs 4-5 years behind his/her grade level
• 90% of hearing impaired 15 year olds in the USA are given a Stanford Achievement Test (SAT) lower than their grade for mathematics.
• The average score for Hearing Impaired children when given the SAT test appropriate for their grade level is comparable to the scores of the lowest 2% of students w/o hearing impairment
• In 3 studies comprised of more than 500 children with levels of hearing impairment ranging from the most mild to profound, there was NO CORRELATION OF THE LEVEL OF HEARING IMPAIRMENT TO THE SEVERITY OF POOR PERFORMANCE IN MATHEMATICS.

**These statistics can be found in research comments on pages 1-9 of Teaching Mathematics to Deaf Children by Nunes

SHIFTING GEARS

I have discussed at length how difficult it is to get a diagnosis of hearing impaired when your child is not profound or severe, though a delay in diagnosis caused language and learning delays just as severe.  I have also discussed the many other diagnoses that are likely crossed in the pathway to finally recognizing the hearing impairment.  However, I have yet to discuss how to help these children overcome their disability in terms of education; which is my current topic of interest in seeking to help my children.  Considering a healthy child, diagnosis is probably of little value, except when education enters the picture.  So if I did not discuss the help these children require to succeed educationally, I might as well not write down these experiences.


To address this, I have decided to first tackle  the realm of mathematics.  Right now I am reading a book entitled "Teaching Mathematics to Deaf Children" written in 2004 by Terezinha Nunes, PhD from Oxford University.  In reading the title, do not be misled by the term 'Deaf'.  As I have read the book, it is clear to me that the British refer to all levels of hearing impairment, even the most mild cases, as 'Deaf'.  When I seek out information I am most interested in literature written after  2003, because this is when the guidelines for hearing impairments changed dramatically.  This book is up to date. 


The great thing about this book is that it is a compilation of researches with Hearing Impaired children from which are derived appropriate methods in teaching these children. For me this is fantastic as it will be time saving.  I am very research driven.  I have found that researches tell you the collective experience of the average child in the same circumstance. Being that there has been a great call to make sure that evidenced based methods and materials are used in all special education programs regardless of the disability, this book will be a great source. Having all the studies in one place will make it much faster and easier to discover what methods are appropriate for my children. 


The posts to follow will discuss what I find as I read this book.

ALEX AND HEARING AIDS UPDATE

This is the best picture I could get of his hearing aids.  They are absolutely tiny and are great for him.  Anyhow, we wanted to give an update of how he is doing.  When we first got them the Audiologist started them at half the strength, so that he would not be overwhelmed with sound.  Today we went in and she turned them on all the way.  Again, when she asked him how he liked the way they sounded afterwards, he just smiled his million dollar smile.  I love seeing him smile like this in reference to his hearing aids.  It just is reassuring to us that they are right for him.  

We were also having problems with one of the aids for the last week and a half, because a connection was loose.  We told her about it and she was actually able to pull up how many hours a day it was functioning.  The right side was on 9 hours and left one only 3, so there really was a problem.  He really was not getting any benefit from the left aid.  But she fixed it and he is good to go again.

I know that most of you are really interested in hearing updates on speech progress with these, so we will tell you what we have seen so far.  It is really neat to listen.  He has started to use prepositions (the small words of the sentence that help with understanding) and has used many abstract terms.  For his birthday he got a game and he told me "we have to figure it out." I was like "OH, Really", where did you learn about how to use 'figure' this way in a sentence? (Hearing impaired children typically do not speak with prepositions or abstract terms). Today he was counting his money in the car and said 1 dollar followed by 2 dollarS, 3 dollarS.  It was amazing to me to hear him using plurals - adding the S at the end- and correctly identifying when to use them.  When I told Saul about it, he commented, "yeah, I know!.  I was listening to him this morning and he told me, 'he slippED' ".  It is so nice to hear these word endings coming together! And that is only after having his aids for 3 weeks with 1 of them not working 1/2 the time.

I can't wait to see how he will be next month! 

HOPE TO EMPOWER. . .

Please be aware and understand that I am not an Audiologist nor a child psychologist.  By trade I taught High School Mathematics for some time and did work with ESL and Special Needs children. My experience with hearing impairments comes  from working with my own children for the last nine years, reading and researching every diagnosis that was mentioned to us. 


Through this blog I hope to inspire other parents to take control over their children's needs and advocate for them as I have learned to.  While doctors have lots of knowledge that is very resourceful at times, they do not live with your children and therefore do not have the experience that you have with your children.  Especially in a situation of having a child with special needs, the parent is invaluable in appropriate intervention.


Seek out the knowledge for your self and research, research, research.  Seek out the best resources; those published by governmental or educational entities (universities and/or their hospitals)  from any of the major countries are very helpful as are others. Consider also that the doctor is not going to have all the most recent information; seek the most recent sources and studies for clarity. If what you come to find and feel is right, is in harmony with what your child's doctor is telling you, then you have a good doctor.  If not, get a second opinion and be sure to share your concerns.

STUDIES TO ASSIST IN NEW KNOWLEDGE

I would love to see a study completed which gathers the hearing thresholds of those who have diagnosed dyslexia, CAPD/APD, and ADD/ADHD.  


Typically when these types of studies are performed the examiners break the hearing thresholds down into classifications of 'minimal', 'mild', 'moderate', etc. In order to allow for optimal analysis, the threshold must be in the raw numeric form rather than broadly classified as normal, minimal, mild; I suspect the impairment would fall in the upper limits of what we currently classify as normal (0-15dB).  The numeric form would allow an easier analysis of a trend as applications of graphs could be used and likely help define a more appropriate and lower threshold value of what a true hearing impairment is.  Would we find that there is, in fact, a lesser value that should be classified as hearing impaired?

MY PERCEPTION

Alex was assumed to have had Dyslexia, CAPD, and ADHD by several teachers and therapists. However, no testing was in agreement with CAPD nor ADHD and he is still too young to determine Dyslexia.  All of the symptoms represented by all of these possible diagnoses, however, are in agreement with a hearing impairment (as the previous 3 posts display), which he does have.  Do we find it interesting that many times children with Dyslexia or CAPD often have ADD or ADHD?  Maybe there is really only one diagnosis: hearing impairment.


Hearing impairment is a 'blind' disability for a child does not know what he is not hearing, because he does not know what he is supposed to be hearing. School aged Children who are prescribed glasses because they cannot see well enough to take notes from a chalk board typically do not show any signs to an observer.  Normally they are only found in the mandatory school vision screenings.  Why does the school perform these screenings if the child is not reflecting any outward signs of vision problems? Because they know that not all vision impairments are noticed by observation. So why isn't the same considered for hearing; why does an observer have to be able too see outward signs of impairment?? If vision can be impaired at levels only testing can detect, it seems appropriate to assume that hearing would also have levels of impairment that could only be detected by testing. What educational difficulties would be observed in a child who had an untreated vision impairment at a level unnoticeable by an observer?


I think it may be apparent to any readers that I do not believe that our current levels of hearing impairment are adequate and only address those levels of impairment that have apparent implications in the infant toddler period to any observer, but what about the periods that are marked in education of learning letters and sounds, then applying the knowledge to learn to read. These two pieces are the pieces that are typically weak in those children who present with Dyslexia or reading difficulty and they are typically addressed in kindergarten and first grade.  Which means, a lesser impairment may only be apparent to an observer once the child is in school , just like those children whose vision impairment is only apparent once they are in school. 

DYSLEXIA AND HEARING IMPAIRMENT

So if you have read the article from PBS.org on Dyslexia (on the right hand side of this blog), you now know that it is poorly understood by the general population or more appropriately, completely misunderstood.  Most people believe that Dyslexia is characterized as a visual disability in which an individual perceives letters reversing and flipping as they are reading.  In fact, this is not the case.  Dyslexia is a disability in which the individual has a weak phonemic awareness or in simpler terms ability to hear the similarities and differences between phonemes or letter sounds. It is a language-based disability in which a person has trouble understanding words, sentences or paragraphs where both oral and written language are affected (site pg 9). It also affects both receptive and expressive language (site). (So far it seems we are describing a mild or possibly moderate hearing loss).  


Characteristics of dyslexia are:

• late to recognize letters
• trouble rhyming
• difficulty listing words that begin with the same sound
• slow to learn the sounds of letters and letter combinations
• difficulty recalling the sounds of letters and letter combinations rapidly
• trouble learning to recognize words
• difficulty learning to decode unknown words
• reads slowly and/or in a word-by-word manner
• reluctant to read
• weak spelling
• writes far less than other children
• difficulty understanding someone talk in noise

They also have difficulty with recognizing common 'sight' words.  All of these characteristics are also apparent in Hearing Impaired children.  The Hearing Impaired children, however, take the 'sight' word difficulty one step further: they usually omit them from their speech too, especially when the impairment was prelingual (before learning to speak).  Hearing Impaired children many times never develop the ability to rhyme.  And all this despite both groups exhibiting normal intelligence.


Now there are techniques that are successful in remediating the difficulties associated with Dyslexia and typically require intense drilling on letter/sound recognition and coordination.  This is also a technique used with hearing impaired children (primarily the lesser impairments) in order to strengthen their reading, writing, and spelling skills.   FM systems are also used in treatments for Dyslexics just as in cases of minimal and sometimes mild hearing impairment (site).  Dyslexia is also thought to be a result of frequent ear infections and glue ear in childhood (site), which are temporary hearing impairments that can lead to long term impairments if left untreated. 


All of the similarities of symptoms and signs of Dyslexia, the effects on education, and remediation give strong implications that there is likely a lesser hearing impairment that is not being recognized.  Would hearing aids resolve the issues of dyslexia at a faster pace than the remediation? Would they make learning easier for Dyslexic children?

ADHD - 68% ACTUALLY HEARING IMPAIRED!!

Last year while Alex was in first grade we were getting into the peak of our search for appropriate diagnosis.  I remember taking three different tests of ADD/ADHD to the school for teachers and aids to fill out.  I also remember picking them up the morning we were going down to Arkansas Children's Hospital.  I did not have a moment to review what was written before leaving the office, so I had to look at them in the car.  It was a good thing, I did not have a chance to look at them!!  As my readers, you need to know that the school district has played the 'enemy' quite well for us; these tests were no exception.  I was so frustrated by their marks, because their answers were clearly not a representation of my son. I am not sure if I had mentioned it in an earlier post, but the school was working for a diagnosis of Autism; their marks were clearly in light of this.  I knew that in this instance they were making a gain.  When we got the results I was pleasantly surprised and probably laughed in spite of the school, because he was not classified as ADHD/ADD by any of the three tests! Siiiiiiggggghhhh of relief!!  Needless to say, these records, despite having been completed by the most reliable Developmental Center in Arkansas, were rejected by the school. . .But that's another post.


In comparing behaviors of ADD/ADHD and Hearing Loss the characteristics are strikingly similar.  Symptoms related to both of these diagnosis and apparent in school aged children are:

• academic difficulty
• inappropriate responses to questions
• do not complete assignments
• trouble sustaining attention during oral presentations
• difficulty following directions 
• Impulsiveness and acting out
• poor self concept
• low self esteem
• fewer social interactions with their peers
• greater stress
• more likely to drop out of school
• tend to repeat grades 

(site)


When children present in a school with these symptoms, the first thought is ADHD and usually there is no 2nd thought in administering the test.  Unlike Autism and CAPD, a hearing test is not required before a diagnosis of ADHD is given.  In our experience, in dealing with our school and district, despite the fact that I communicated to them my feeling that Alex was hearing impaired, they still plunged forward in their own objectives without consideration.   If he was diagnosed with ADHD the treatment would have been medication and a set of educational modifications that would be completely inappropriate for a hearing impaired child. (This is why it is so important that the parents advocate for their children)


"Anderson found that 89% of hyperactive children had 3 or more episodes of ear problems, while 74% of the hyperactive children had 10 or more episodes. Of the hyperactive children receiving medication for hyperactivity, 94% had 3 or more episodes of ear problems and 68% of these children had abnormal hearing. That is 68% of the ADHD children had an undiagnosed hearing impairment!! Anderson reported that in the learning disabled (LD) population, 20-25% of the students have histories of, or ongoing, ear problems related to hearing loss. As many as 38% of the LD student population has been found to have abnormal hearing thresholds." (site)  Total shocker!! What a reality check!!  


(Anderson was the hearing specialist for Florida's Department of Health Early Childhood program for 9 years and has specialized in Educational Audiology for 25 years. About Karen Anderson) 


Overall, be careful in seeking a diagnosis of ADHD.  Be sure to check every possibility to ensure that your child is getting an appropriate treatment. As for me, I am interested to know exactly what the numerical hearing threshold is of those 68% of ADHD children in Anderson's study who were actually hearing impaired.  Were they predominantly 'minimal', 'mild', 'moderate'. . .

CAPD or CENTRAL AUDITORY PROCESSING DISORDER

Patti Martin, in her emails to me made reference to a condition she calls 'auditory processing issues' I am assuming she is referring to Central Auditory Processing Disorder.  CAPD is not very well understood by many professionals, no one can 'pin point' exactly where the malfunction may be, and in our experience many professionals question the validity of the diagnosis (site, last ¶).  I am not a believer myself.


The problem that I have with it is the fact that a hearing impairment must be ruled out first.  If you have a patient presenting with a loss like my sons, which apparently is not significantly recognized, then a hearing loss may be over sighted en route to a diagnosis of CAPD. Now all people of any age with a hearing impairment of any degree will have poor auditory skills including attention and memory; hearing impairment presents with the like APD. If you think about it, you don't pay attention to, what sounds like, meaningless noise and you don't remember what you don't hear. That being said, many times the treatment for CAPD will involve an FM system or a hearing aid.  Which says to me hearing impairment.  


CAPD presents with a Pure Tone Average considered in the normal range (25dB yesterday and 15dB today) and a normal ABR.  In other words, the PTA detects normal hearing at the middle ear/Cochlear level and the ABR detects normal hearing at the brain stem level.  So somewhere between the cochlea and the brain stem, the message gets scrambled enough that it is not understood, but it gets to the brain stem. It does not make sense. Now considering that it is much easier to hear a tone and know it was a tone, than it is to hear a message and know what the message said; it is a very hard task to hear a message at the quietest level your ears can hear and understand it.  So consider that the message was just too quiet to understand in the first place;  it may well have been a tone which carried no message. Yet hearing aids or an FM system is a remedy for the problem; turn up the volume and the message is no longer scrambled? Maybe it was never scrambled in the first place.


Before we can invent new diagnosis like CAPD of which validity is questioned by many professionals in the field (site, last ¶), a minimal level and even a more minimal level of hearing impairment needs to be considered.

FINAL EMAIL FROM ME TO DIRECTOR OF AUDIOLOGY ACH (4-27-2010)

Patti, 

Thank you for your offer of a second opinion, but it will not be needed. Not short of a miracle a friend of ours has a son who recently got hearing aids for the exact same loss.  He is a 3 year old with similar speech to how Alex was at that age and also failed his initial newborn screening. We felt really blessed as when we went to the same audiologist they used, our son was finally prescribed air conduction hearing aids; he will get them this Wednesday.  I am tremendously grateful as I feel, regardless of how this impacts his speech, he needs the hearing aids to prevent additional difficulties in education.  So many pieces of the audiological picture just does not match up. Never present OAE's, always type As tymps, absent middle ear reflexes. . .I mean I understand passing off one of these things permanently missing, but all of them together. . .  

I have been through test after endless test with my son.  I have seen the facts of education at school, through the Dennis development center and through early childhood intervention. He has been tested by the school psychologist, the school speech therapist, Dennis Developmental, the state education consultants, the ACH Genetecist and endocrinology. We have been more than thorough. We have done every recommended battery for my son to check every possible diagnosis.  Nothing has been turned up.  I have stuck to hearing, because I have noticed a pattern in these tests.  His IQ is consistent with a minimal hearing loss.  His sound omissions on the Goldman Fistoe is consistent with his Audiogram. The Genetecist pointed us back to the hearing loss when his tests drew a blank. He has struggled with reading, writing, and spelling.  We have found programs that work for reading, writing is coming along through practice.  NOTHING  works for spelling and Apraxia techniques DO NOT work for speech nor ever have. So many things are consistent with a hearing impairment, for which there is a solution.  On the other hand there is no treatment for Apraxia.  Why sit here and do nothing, if there IS a possible solution?  Still again why would we want to complicate his education by untreated hearing loss. If an undetected minimal hearing impairment affects the average students IQ by 1 standard deviation, how much more severe would the affects be on a student with another disability. 

ASHA's classification of Minimal for a child is a PTA from 16-25dB the American Academy of Otolaryngology's classification is mild for a PTA from 15-40dB there is no requirement of the plotted PTA's to cross the speech range per either of these entities. I find it interesting that hearing aids would not be prescribed at ACH until the PTAs reflect that some speech sounds are not heard.  Isn't that too late? Speech sounds should be loud enough to be intelligible not just audible.  ASHA's recommendation of amplification 15dB over threshold gives insight to this.  Children need to have access to speech sounds with at least 15dB of strength.  By the Audiogram, Alex does not hear 'Z' and 'V' and hears the other low frequency speech sounds at about 5dB only hearing the loudest 3 at the recommended 15dB.  The high frequencies are the same, 5dB gain (are you surprised that he does not produce 'Z', 'V' & 'J' or 'F' & 'TH' and produces 'S' imperfectly?) .  Look on Karen Anderson's website http://www.kandersonaudconsulting.com/Listening_and_Learning.html  She states in her document on Reverse slope losses that a hearing loss of 25-40 dB in the low to mid frequencies causes a child to miss 30% of speech information if not amplified and some sounds may be heard inconsistently, which may affect speech production. Does this not seem bothersome enough for a child to need hearing aids?

Only 1/12,000 hearing impaired individuals have a reverse slope loss; that is 1 appointment in 5-6 years of working as a full time Audiologist. It makes me wonder how much information is really known about how this type of loss affects a young child prelingually.

I do hope that you take into consideration these facts. And still again, I do hope that I will make the way for the next family less difficult.

Regards,

Sara Solis

LETTER RECEIVED FROM DIRECTOR OF AUDIOLOGY ACH (4-26-2010)

Mrs. Solis—thank you for your note.  I appreciate your comments and certainly wanted you to know that Dr. Stroud wanted to respond to you in a way that would speak to your concerns, but also encourage you to seek additional information outside of the audiology realm to get the best picture of your son.  She  did visit with several of the Audiologists in our department informally about what optimal recommendations they might make based on an audiogram like your son’s with the reported speech issues.   It is very difficult because based on the test results that I have seen (which is definitely limited), I would not expect the significant delays in speech to be caused by the hearing loss in the lower frequencies.  Also,  generally we apply the term minimal or mild when the hearing loss impacts hearing across the speech range or within the mid-high frequency range (the range that most consonants are found).

My understanding is that you are working with Elizabeth Bowden as you undergo a trial period with a BAHA and traditional amplification.  As I have not been involved in your son’s care, I am not confident that I would have made the same recommendations, but recognize the need to investigate different options and look for solid verification of benefit.  With my limited knowledge about your son, I see a “red flag” for auditory processing issues potentially that may warrant investigation.

At ACH, we are deeply involved in early identification and aggressive management of hearing loss.  All of the references you provided are a part of what we recognize as best practice and many of us on our staff are involved at both the national and international level in seeking a solid evidence based for what we do.   I apologize again for your disappointment in the response you received from us as our goal is always to help families find answers.  I would be happy to offer you a second opinion with another member of our staff, etc., if you would like. 

Sincerely,

Patti

Patti F. Martin, Ph.D.

Director, Audiology and Speech Pathology

Arkansas Children's Hospital

Her response really just left me dumbfounded.  She is an Audiologist.  She has her degree.  She works with children with hearing impairments.  Any regular person could look at an Audiogram and see that the bulk of speech sounds is in the low frequency range (see here).  Her belief is that they are in the high frequency range.  That is a novice error.  Karen Anderson who was the Early Childhood Invention specialist in Florida, Educational Audiologist Karen L Anderson, with decades of years of experience working with children effected by hearing loss on all levels and all ages stated clearly in her message to me that a loss in the low to mid pitches would DEFINITELY cause problems with accessing verbal information.

LETTER TO DIRECTOR OF AUDIOLOGY ACH (4-26-2010)

Patty,

I write you because as a parent of 3 hearing impaired speech delayed children in Arkansas, you are part of the front line in my advocacy for my children.  I am quite surprised and disappointed in the service and attention ACH has given our family.  I am absolutely shocked ACH is apparently unaware of the most recent published information on management of children with Minimal Hearing Loss.  While I know that my concern will not be of sufficient caliber to render advocacy from you on behalf of my children, I speak to you in hopes that it will help children that may follow behind us in their trek for appropriate management of hearing loss.  

This decade has been a decade of growth for the world of audiology research and I expect that growth and accumulation of knowledge will continue for years to come. Just a year ago I could not find 10% of the information on Minimal Hearing Loss that I have been able to find this year. Below I am supplying you with quotes from the most up to date publications including JCIH 2007 Position Statement and the Pediatric Amplification Protocol of 2003 from the American Academy of Audiology.  Both of which support my concern for my children in not being 'qualified' according to ACH to receive amplification.  

None of these measures were followed for my son as he was born in 2001 and they were not yet published.  However, all of them support that my son needs (and needed from birth) amplification for normal development of speech and language. I am so glad that we have found an Audiologist else where who does support us in our concern and is aware of the most recent information to know my son needs amplification.  I hope that you can be a forerunner in the efforts to help ACH get on board with the most recent recommendations.

Thank you for your attention. 

Sara Solis

Pediatric Amplification Protocol October 2003 – American Academy of Audiology

“Special consideration should be given to the fitting of amplification on children with unilateral hearing loss, minimal or mild hearing loss, profound hearing loss, and auditory neuropathy.” (pg 3)

Joint Committee on Infant Hearing – 2007 Position Statement:

“Developmental monitoring should also occur at regular 6 month intervals for special populations of children with hearing loss including those with minimal and mild bilateral hearing loss, unilateral hearing loss, and neural hearing loss, because these children are at risk of having speech and language delay.” (pg 910)

“Amplification Considerations for Children with Minimal or Bilateral Hearing Loss and Unilateral Hearing Loss.”  Gavel, McKay, Tharpe.  Trends in Amplification 2008.

“Children with minimal and mild hearing loss should be considered candidates for amplification and/or personal FM system or soundfield systems for use in school.” (pg 45) “Children with MBHL [minimal bilateral hearing loss] and UHL are at risk for academic, speech-language, and social-emotional difficulties” (pg 51)

ARKANSAS CHILDREN"S HOSPITAL (4-26-2010)

Jan,


We are no longer frustrated, we are getting help.  We have 3 children with depressed PTA scores 1 at 15dB and 2 exceeding 20dB all since birth and all with delayed speech.  Our son who has scores that are not depressed [a 4th child no impairment and test scores at 0dB and 5 dB] has advanced speech and understanding. The one with 15dB has stronger speech than the one exceeding 20dB, though still delayed. Coincidence?   The oldest has undergone thorough speech testing including apraxic measures 3 times now.  You and your team may never understand me, but you haven't seen what I have, nor have had the time to get to know as many speech/hearing impaired children as I have at the level I have involved myself with them.  You can care for your patients and interact with them, but a mother does so much more for a child than a therapist or Dr.  I am sure you know this, you have a child too.

It would really be interesting to see if there was any consistency of hearing patterns between children with Articulation disorders or Dyslexia, as these issues are very commonly seen in the hearing impaired population and I believe that these are examples of the least impairment a hearing impairment can cause.  Then maybe we would know the truth of what the threshold of a significant infant hearing impairment should be. If ACH ever does this, let us know, we  will be the first ones to sign up.

Best of luck!!

Thanks for letting me know your stand.

Sara

ARKANSAS CHILDREN"S HOSPITAL (4-26-2010)

Dear Sara,

I know that you are disappointed that Dr. Berlin is not available, but trust he was able to provide you with useful information.  In my professional judgment, I continue to feel that Alex’s hearing does not contribute significantly to his speech and academic performance.  I would not recommend hearing aids—either traditional or bone conduction.  Additionally, I would strongly recommend that you pursue in-depth testing to rule out motor sequencing issues such as apraxia, etc.  I was able to discuss all of the results with several of my colleagues, including Dr. Patti Martin and they concur. 

I recognize that you are frustrated over this issue and apologize that I am unable to assist you further. 

Sincerely,

Jan Stroud

ARKANSAS CHILDREN'S HOSPITAL (4-24-2010)

Jan,  

Thanks for the quick response.  It is no longer feasible for us to go see him. He is now in Florida; he left Louisiana after Hurricane Katrina. Apparently, the documents I supplied were complete enough for him to give me some info on.     

I am sending you the newest tests from December 2009 that show the additional hearing loss and the results from February 2010 that confirm the loss. Both tests were completed with his back absolutely to the examiner, which was never done before.  We have trialed a Bone Conduction aid and will upgrade to hearing aids on Wednesday. We are hoping that you can give us your opinion on how this type of hearing loss affects a child in school and what YOU would do for it. This will help us decide if we should make another trip to ACH or continue with our current Audiologist, since we cannot see Dr. Berlin.  Please don't hesitate to call if you prefer to talking rather than email.

Thank you.

Sara

CORRESPONDENCE - ARKANSAS CHILDREN'S HOSPITAL

In keeping with my blog, I felt guilty in my experiences with Children's Hospital, because while they would not recommend hearing aids when his impairment was 15-20dB, they may have recommended hearing aids having the knowledge of the Audiogram completed with his back to the Audiologist.  To be completely fair, I gave them a chance to rejuvenate them selves.  The following posts will be exactly those emails.


Prior to actually deciding to email ACH about the scores, I had communicated to Karen Anderson who is the Educational Audiologist out of Florida.  I posted these emails first, as that is how they fit in the timeline of events.


Just a note to understand those posts: they do make reference to Dr. Berlin, who we had been in communication with a couple of times in the past years, and who is a professional that has been in the field of Audiology since its birth.

RESPONSE FROM EDUCATIONAL AUDIOLOGIST: 4-1-2010

Hi Sara,

                

You are obviously very concerned about your son and are not feeling comfortable with the information you have been given from  your audiologist. I am assuming that you have brought him to an ENT doctor and that there is no ongoing middle ear problems and he has given you an explanation for the type As tymps (stiffer eardrums). Many times this is just ‘normal’ for an individual even though most people have more eardrum mobility.

                

A bone conduction hearing aid delivers the sound signal through the bones of the head so that both cochleas are being stimulated. This is why only one BC aid is needed. In general, hearing aids are made so that they amplify more in the high pitches than in the low pitches, where it seems that your son has the most trouble hearing. A reverse slope loss can be very difficult to fit with the available technology. I don’t currently fit hearing aids so I am not aware if there is any new highly flexible hearing aids that could possibly work well for him. Based on what you say, if he is experiencing a 35-40 dB hearing loss in the low to mid pitches it certainly could cause difficulties with accessing verbal instruction in a typical classroom setting.

                

My best advice to you at this time is to seek another opinion. Bring all of your records to another audiologist. Thankfully, I can highly recommend Patti Martin, at the Arkansas Children’s Hospital in Little Rock. I realize this is a drive for you (I looked up your area code) but I think it would be well worth your time and your peace of mind. I know Patti personally and she is an excellent pediatric audiologist who is also very caring when listening to parent concerns. In the meantime, it wouldn’t hurt to ask your son’s teacher to fill out the SIFTER (on my website) and you and he could both fill out the versions of the CHILD test. To do the CHILD he would need to be honest about how he feels he is able to listen – some kids can do this at 7-8 while others need to be older. He would need to know the importance of honest answers so he won’t try to please you by answering better/worse. This test information should help pinpoint under what listening conditions, if any, he is having difficulty (CHILD test) and in general how he is functioning in the classroom (SIFTER). If he is a good reporter he could also fill out the Student LIFE test, which would provide more information about listening in the classroom. Any or all of this information, along with the records and your concerns would be of assistance as Patti works with you to figure out what can be tried. Once the hearing issue has been satisfied I strongly suggest you work with your school district to see if he may be eligible for any special support services if you haven’t done so already.

                

I hope this helps you and your son Sara. Hang in there.

Best wishes,

Karen Anderson