Hearing Issues for Students with Deafblindness #2 This video is posted online with the following chapter markers: Chapter 1. Intro with Audiologist - Introduction of Lisa Sutherland, Educational Audiologist Chapter 2. Prep for a Hearing Test - Discussion about ways to ease student stress before an audiological test. Chapter 3. Audiological Testing - Discussion of different types of audiological tests. Chapter 4. Collaboration with Audiologist - Discussion about how parent/TVI observations about a student can help audiologists perform better testing. Chapter 5. Strategies to Prepare for Testing - Discussion of different ways to help students with multiple impairments prepare for an audiological test. Hearing Issues for Students with Deafblindness #2 Transcript [ Music ] Chapter 1. Intro with Audiologist Adam: Welcome, everybody. This is the second installment of the hearing issues webinar for students who are deafblind. And I am Adam Graves and I'll be hosting this session. And I'm very grateful to be joined today by Lisa Sutherland, who is an educational audiologist, and also off camera here we have Chris Montgomery, who has also done some of the work in preparing for this. And we also have Kate Hurst who will be helping us run this webinar. And so we're just going to go ahead and get started. We're just very thrilled to have Lisa here because she knows a lot more about hearing than I do. And so I'm just going to ask her questions and invite you to do the same. And I'm just going to start out, Lisa, with introducing you. You are obviously, as we mentioned before, an educational audiologist, so if you can explain to us what that means and what's entailed with that. [ Start slide: ] Lisa: Okay. I'm an educational audiologist that contracts with districts to support students who have been classified as having an auditory impairment. [ End slide: ] So in my current job situation I go out to student's campuses and I make sure that their hearing aids and their listening equipment, their FM systems are working well. I consult with the staff there to make sure that they understand the impact that that hearing loss has on the student's education, help them solve problems when equipment issues come up, interpret the testing that comes in from community audiologists, and things like; that that I've been doing lately. Chris: Lisa, can you tell us what staff when you go to a school, which staff are you usually working with? Lisa: I'm generally working with the teacher that's in that classroom. Depending on the campus situation, there may be... situations where my best contact person would be the school nurse, for example. I have a student who she has been the reason why we've been able to be successful with the equipment is having her involved. But we try to work with all of the staff that is interacting with the student so that they understand how to accommodate and make modifications for the students and how to use the equipment when issues come up. [ Start slide: ] Adam: So I think you touched on a lot of these -- these duties and things that you do. [ End slide: ] [ Start slide: ] Lisa: I was going to add that educational audiologists in different settings sometimes do different -- are able to do different things. I am traveling now to different campuses with my little hearing aid tests box in a suitcase, [ End slide: ] but there are audiologists in town and across the country that might actually have access to a sound booth and they might bring students to them to get a variety of types of testing. And what I do for each district differs depending on what the district and individual kids' needs are. So you may -- if you're in a district with an educational audiologist, touch base with them and see what they can do for you because there may be other things that they can do that can support. Chapter 2. Prep for a Hearing Test Adam: Okay. So we have some questions about preparing for the test. [ Start slide: ] And these are things that as a TBI, some of the things I've done in the past with some of my kids. [ End slide: ] To help prepare them for the testing, and also to provide a little bit more information to the audiologist when we go into the test. For example, I think it's really important for the teacher or whoever is going with the child to the test, to know the child's etiology because it typically -- etiology because it will typically tell you what their hearing might be like or what hearing losses to look for. And then I think it's also really important and one of the things that the audiologists that I have worked with have said is that making a list of how the students respond to environmental sounds and speech helps them, as well. Do you find that to be the case? Lisa: Absolutely. I mean, as far as etiology goes I think there's a lot of information that can be provided to the audiologist -- hopefully the audiologist is doing a good history themselves too, but certain genetic disorders that are going to be a red flag for audiologists in terms of hearing loss or if there's a potential for a progressive hearing loss and other things that they should be looking out for. So any information you can provide about that is really important. If the child is someone who gets a lot of ear infections and you've seen that happening or it has happened recently, that would be a really good piece of information to share so that the etiology piece, absolutely. Or any family history that maybe you have been able to share that you're aware of that you can share with the audiologist would be really, really helpful. Family history of hearing loss that maybe we might not know right away if you have access to that information. The observations are so important and really a piece of information that we don't always have. We see these kids and these families in a very unusual situation and not typical situation in terms of both the lack, maybe, of background noise and distracting information, but also the kids -- it's a medical setting. The kids may not be comfortable and we may not get a real picture of what their abilities are because they're nervous in that situation. So any information you can provide about how they're behaving in school. I have a student right now that we have an audiogram that looks like one thing, and because I only see this child in very limited situations, I might not know that on a daily basis that the deaf ed teacher that I work with said "You know what? He did this, this and this." And we look at the audiogram and say that doesn't make sense. So now we're bringing him back to recheck that testing, but if we didn't have that information I think audiologist would go forward thinking, "This makes sense to me." So that's really important. [ Start slide: ] And the last is the listening response. We've talked a little bit about this, especially with kids with deafblindness, but also all kids. [ End slide: ] If it's a student who reacts in a certain way or has a certain length processing time, that's a really important piece of information to know. We're talking about audiologists -- at least when I worked in the clinical setting... we would be overbooked all the time. I'm sure that people feel that whenever they go in a medical setting there's four people booked for the same time as you. So I think the audiologists are frequently feeling a lot of pressure to get people in and out as fast as they can and everyone is trying to move as efficiently as they can and have a certain sense of the rhythm of how a hearing test usually goes; I respond, and I have just kind of a feeling of when typically somebody responds. But if it's a child that takes longer to kind of process information, you see responses out in the real world that just are a little bit longer than you would think, that would be really important for the audiologist because, if it were me I might be moving to the next level, turning it up thinking oh, they didn't hear it. I'll turn it up, turn it up. And maybe he heard it three beeps ago but because I'm trying to move, have gone past that. So I think if someone were to say wait a minute, wait a minute, there it is, then I would go okay, okay. So I think all of those would be very welcome information for an audiologist. Adam: Yeah, and I think that is really important because that happens a lot, you know, that it takes awhile for the students to register that they've heard a sound. So just letting the audiologist know ahead of time that -- to sort of slow down the testing. Lisa: Yeah. I think what happens is have frequently with kids a very small window of time that they're going to think that this testing is a fun thing to do. [ laughter ] So if I have now wasted a good chunk of that figuring out what I'm moving too quickly and now I need to back up and start again, I've just lost maybe the five, ten good responses I was going to get I've wasted and maybe I've accidentally made worse a response or a non‑response that I didn't mean to because I've been moving too quickly. Chris: Lisa, I think that's really interesting conversation because I know right now I'm doing a Functional Vision Assessment on a student that's got a Cortical Visual Impairment. And I tend to think she's got an auditory cortical impairment, as well, or auditory processing disorder, but I know she has probably a 30‑second latency between when you present something visually and when she'll respond. And that's stuff that she knows and understands -- Lisa: And 30 seconds, when I think of how fast I'm trying to move through a test, I would have turned it up, you know, five times. Chris: That was five pages ago. [ Laughter ]. Lisa: Exactly. So that would have been, yeah, really, really important information. Chapter 3. Audiological Testing Adam: Well, I'm just going to keep going and go right into the testing part of it. And hopefully some of these tests will be familiar to people. [ Start slide: ] And if not, then it will be new information. So would you just kind of describe a little bit the types of tests and what parts of the ear you're testing for in the various tests? Lisa: Sure. Some of the stuff we had talked about before that would be helpful for kids to be familiar with. [ End slide: ] Going into a test would be even -- the very first thing that I do when a kid comes in is I take a peek in their ears. And that's something that they probably have had at the doctors, which may or may not have been a useful experience in terms of when they come to see me. So they have to be comfortable with somebody -- it doesn't hurt, but we do grab their ear and get real close, you know. So that is something that they need to be comfortable with. [ Start slide: ] And I think on the screen there we have a picture of the part of the ear that we're looking at there. So we're looking at that ear canal and the eardrum. And there's a picture on the left there of the otoscope. [ Inaudible ] And... Adam: And what are you looking for when you're in there? [ End slide: ] Lisa: I'm looking for a couple of things. The first is just seeing if there's any wax or anything in the ear canal that might be blocking the sound. A lot of times kids with ear infections you will see drainage in the ear a canal or redness in the ear canal if they have -- I'm not sure which way to look. [ laughter ] If they have an infection in the ear canal itself. We're looking at that eardrum, that tympanic membrane. You can see if somebody has tubes, PE tubes. You can often see those. Adam: What does PE stand for? Lisa: Oh, It's been so long. Pressure equalization tube. So what is going on, is if a child gets fluid in that middle ear space back behind the eardrum. [ Start slide: ] And that happens when you get real congested in your eustachian tube. You can see that in the bottom of the screen there. If you get congested it closes up. So fluid fills up that middle ear space and there's nowhere for it to drain out because that eustachian tube is closed. [ End slide: ] So the fluid goes in there and sits there for a little while and it gets an infection. And for some of us our eustachian tube when we're not congested anymore it will open up and drain out. For others like my kid, it would just never, ever clear. His ears would never clear. And that also has do with the position of the ear canal when you're younger. It's a little flatter. When you grow a little a little bit more tilted. So it would always be filled with fluid and sometimes it would be infected and sometimes it wouldn't. What they would do is put a tiny tube in the eardrum so the fluid drains out through that little tube in the eardrum rather than down through the eustachian tube. Adam: Okay. That's something you can see. Lisa: That's something you can usually see. So that's what we're looking at, what we're looking for with the otoscope. So we're peeking in there for a few seconds, so they have to be able to kind of sit still for a minute while you've got that down in their ear canal. So that's something that can be challenging. So that's kind of the first step. Oh, I was just going to move on to the middle one, or the middle ear evaluations if you guys are ready. Adam: Yeah, go ahead. Lisa: So the next thing that I typically do after an otoscopic exam is called the tympanogram. [ Start slide: ] Lisa: And it's a measure of how the eardrum and the middle ear bones are moving. So what happens is you can see the tympanometer on the left‑hand side and see draped on the side of that machine is a probe that we put in the ear canal and it pumps air. So the student is going to feel you holding something in their ear and they're going to feel that air pressure change from the tympanometer that is kind of blowing and sucking air into and out of that ear canal, and that will make the eardrum move back and forth. And again, it doesn't hurt, but it's a weird feeling. It's kind of like when you're going up and down in an airplane. [ End slide: ] And the tympanometer is also going to make some pretty loud beeping sounds. The student doesn't need to respond. As a matter of fact, they need to just sit still during this test, but again that can be something that's kind of challenging. And the tympanometerry is going to tell us what is going on behind the eardrum and with the eardrum itself. If there's fluid back there, that pressure change in the ear canal is not going to make the eardrum move at all. It's going to still stay stiff because there's fluid back behind it. So, if there's no movement there, we're just going to have a flat looking tympanogram. [ Inaudible ] And then the loud beeping sounds are going to tell us a little bit more about what's going on both with the middle ear system and with the nerves in the auditory system higher up. That would be the second thing we do when the kid comes in for a hearing eval. And then if we wanted to move on -- Adam: How long that test last? The tympanogram. Lisa: That's a good question. The tympanogram is very fast, just a few seconds. And then with the beeps on the end we're still probably talking about, you know, less than 30 seconds. So all together -- Adam: That might be a little bit easier to prepare for if you had a student who was kind of wary of medical situations. Lisa: Yeah, the tympanogram, itself, by itself, without the reflexes, actually, is just literally seconds. And it's the additional part of testing those reflexes that tell us a little bit more, that take a little bit longer get. But it's pretty quick. The next part of the test that -- or the section of the auditory system that we want to look at is the inner ear. [ Start slide: ] So that includes the cochlea and the nerve, the nerve that runs from the cochlea up to the brain stem. And there's a couple of ways of testing it. The one listed on this particular side is one of the tests that kind of think of as passive tests for the student. They don't really have to do anything. So this is a great test to do with kids that aren't going to raise their hand when they ear the beep. It's also the test or one of the tests that they sometimes use for newborn hearing screenings, so they'll do on infants. And it's, again, measuring a little bit, about a portion of that inner ear, that cochlea, the hair cells in the cochlea. So that also requires putting a probe in the ear canal and the student will be hearing some sounds. [ End slide: ] And this one they have to hold really, really still for. This one is sometimes done when somebody is sleeping or sedated, but sometimes kids will sit for it. I've had kids sit for it when I've had a really good distraction. I did it with my own son while he was watching television because that was the only thing that was going to hold his attention. So there are ways to try to get it, but they do have to be really, really still for that test. [ Start slide: ] Adam: Ok, we'll probably talk more about strategy in a little bit. [ laughter ] [ End slide: ] So are there any other tests that require probing, ear probes or things that started into the ear that we haven't covered? Lisa: You know, a lot of times people have been moving from using just the headphones that we all were used to before the big headphones that go over your ears, to using insert earphones. Adam: Are you talking about like the pure tone test when you hear the beep in your ear and you raise your hand? Lisa: Exactly. So you will see people using like the little noise protection kind of foam plugs that you see sometimes except with the tube coming out, so sometimes they will try to use that. And sometimes that's a good solution for kids who don't like the earphones on. They kind of forget you put the insert earphones in sometimes, and they'll be okay once they've moved away. They're like oh, okay, she's gone. And the probes are in or the insert earphones are in. So sometimes they'll use that as opposed to headphones. And actually, people really like insert earphones now, if the kids will put up with them. Adam: Right. Lisa: So that's one of the things that you... might see -- I'm trying to think of what else might be getting stuck in people's ears. And then there's just the headphones. I have kids that really do not want anything on their head. And so there are other kinds of testing that you can do without the headphones, but I think the audiologist is always going to go to headphones first, because we want to be able to test the ears one ear at a time. Once you've decided I can't get the headphones on, you still can get a test in the sound booth through the speakers, but you're now no longer able to figure out which ear is responding. So when you get that type of test you'll see something like, "Hearing at this level for at least one ear." You don't really know what's going on with the second one because we haven't been able to isolate them. So I think they will always go for headphones and give it a good college try before they give up and put them in the sound booth. Adam: Right. Chris: Lisa, do you usually try to run the full gamut of tests in one day, or does that matter to you as far as you're concerned, if you've got a squirmy little guy who maybe can only handle one thing? Or... Lisa: I always go into it hoping I'm going to get the whole thing. And now -- actually, now that you're saying that I was thinking about what that whole battery includes. And in a perfect world not only would they do all of this, right, and they would repeat words back for me and they would raise their hand when they hear a really soft beep. Then I would push it even a little bit more and try to get bone conduction testing, which is a head phone that actually sits back behind your ear, and you hear the same sorts of things on it, but it is a different head phone; and that testing is going to give us information about where that hearing loss is coming from if we see a hearing loss, is it because of a problem in the middle ear or a nerve problem. So in a perfect world I always go into it very optimistic. I'm going to get the whole thing. And then as things start to fall apart, I start throwing stuff. I'm like okay, "I really didn't want that frequency anyway. I'm just going to get the ones that I'm most focused on." And if I can't do that, then maybe the beeps are pretty boring. Maybe they'll listen to words and repeat words back for me or maybe they'll show me body parts, like, "Where's your nose?" And I'll start kind of moving away from that full battery just to try to see what little pieces I might be able to get, and then bring it back if you need bring it back. But my hope is to get as much as I possibly, possibly can. Adam: In one shot. Lisa: In that one shot, yeah. Adam: So with students who or kids, for example, who are deafblind and are non‑verbal, do you have any tricks that you use to try and get a response from them? Lisa: Yeah, I mean one of the -- Adam: Like they can't read words back to you, so are there certain... Lisa: Right. So we will do -- I think we kind of vaguely touched on the whole threshold testing, which are the tests that people might be familiar with when you raise your hand when you hear the beep. So... the most, I guess, adult version of that would be raising their hand or pushing a button when they hear the beep. And then if they're not going to do that or not going to be as reliable, because it's a pretty dull test, we might turn it into a game and kind of the stereotypical play audiometry is you drop the block in the bucket when you hear the beep sound or we build a tower. But I've modified that to whatever I think is going to hold the kid's attention, or even switching it part way through as long as I feel like I'm getting a reliable response. So... whatever it is, I've done all sorts of weird things. Like we're drawing a picture, but you only get to color when you hear it. Whatever it is, if I feel like it's consistent, I'll take it. Adam: And those are the things that you could probably practice before you go to the audiologist. Lisa: Yeah. I've had a kid who has practiced and I've done this in the classroom setting too. We know somebody will go for a hearing test, we might practice -- we're going to practice playing the game where we're dropping the block when we hear. We can do that without audiometer in a school setting. I just go and hold a piece of paper up over my face, so they don't see me, and then, you know, I'll just go beep!, and they drop -- and "Yeah!" you know. [ laughter ] So we practice that a lot. Anything that they can come in familiar with that test would be really, really helpful. Adam: And... and I also have a question about the length of the testing when you go through the whole battery. How long does that last? Because some kids, you know -- Lisa: They're not going to sit for that long. Adam: They might be okay with the invasiveness of it, but it might be the length they have trouble with. Lisa: Yeah, it can take... I'm thinking, if I just did it very leisurely, you know, it could take a half hour, if I wanted to do different levels of speech, I want to see what they hear in background noise. It could go on past that. But I think -- it would be unusual, I think, for somebody to sit for that length of time when -- even the ones that are older you just start to lose them because it's boring. It's hard to attend that intensely for a really long time. So, a lot of times they would be in and out in 15 minutes, because that's about as long as for some of them as they would really sit for me when they're really little. Another test that people may have -- I'm thinking about some of the other tests that kids may do. If we can't get them to do conditioned play, audiometry, we do something called visually reinforce audiometry; which, depending on a child's vision, it might not be a useful test to do. But a sound will come from one side, the student will look towards it and there will be a little toy that plays. "Oh, yeah, they made a noise," and then they go back and then another sound, and they go to look and get reinforced that way. Adam: So if they doesn't have any vision, how would you measure that in. Lisa: You know, it would really depend on if you would be able to use it if they had the ability to vocalize probably. We used to when I first started in audiology we used a lot of observation too. We don't have do this as much, because we have some other testing that we haven't talked about, the auditory brain stem response test. [ Start slide: ] Where the student is asleep for that test and it's somewhat like an EEG, it's measuring that brain stem response to sound. [ End slide: ] We can use that information a lot if we're not able to get the student to do some of this testing. But before we were using that consistently, we would do things where we would just look for any type. Like, they stop sucking on the pacifier and we would say oh, I think that's it. Let's do it again. And it was for me a very nerve wracking way to try to fit a hearing aid, but we don't have to rely on that as much now. And I think that's what you'll see is audiologists will give all of this a shot, and if it's really clear that okay, maybe we're going to get it, but it's going to take six visits and we'll get it 10 minutes at a time, I think most people are going to go, "You know what, let's do a sedated auditory brain stem response test." Get the whole thing so that we can get moving on fitting a hearing aid if that's the direction we're going. We don't want to take four months to get the audiogram. We want to get the hearing aid on them as fast as we can. And as they get older, and they're able to respond we can also get that behavioral information to give us additional information or confirm of a potential testing. So, I think you will see that are at some point if we're not getting a really good picture of what's going on that will be recommended. I think, with an infant it's not as big of a deal you can sometimes get an auditory brain stem response if you just get it during nap time. When they start to get older and if they're not able to lay quietly with their eyes closed for an hour you're going to have to sedate and then everybody is reluctant, you know, justifiably, to go through sedation, unless that's the only way we're going to get that test. But I've also seen them piggyback the auditory brain testing and they have to get PE tubes, dental work, or something; the audiologist might come in on the tail end of that procedure and get an auditory brain stem response. Adam: Can you talk more about that, about the ABR? Lisa: Yeah, So the ABR is the the test that is also used in a screening form, as a newborn hearing screening. [ Start slide: ] And it is a lot like an EEG, in that the student's going to have us insert earphones in, and they're also going to have electrodes taped to their forehead and back behind their ears. [ End slide: ] And there will be different sounds coming through the headphones. It might be a clicking sound or little bursts of tones coming through. And what the electrodes are picking up are the actual activity of that auditory nerve as it leaves the cochlea and starts to travel up the brain stem. So we're able to see this little wave form and "Oh, we know that auditory brain stem is responding." And then we can turn it down, turn it down until it disappears and that gives us a good indication of the softer sounds that they're hearing. So, we can get that through a variety of sounds and it gives us enough information to set a hearing aid for an infant. So you might see a four-month-old wearing hearing aids and that is based on that auditory brain stem response test. Adam: That's really interesting. [ laughter ] It is. Chris: Lisa, would you tell us what parts of the ear does the ABR test? You said -- you lit on it a little bit, but there are certain parts it does and doesn't test. Lisa: Yeah. Well, it starts -- wave one, and there's five waves that they're looking at. It just literally looks like this bumpy line. The first one is where the auditory nerve is exiting the cochlea. And then it goes part way up through the brain stem and there it stops. So it gives us a good indication of threshold, but I think you're hitting on something, as far as what's happening higher up than that, there are other kinds of potential testing that you can do that's measuring more central auditory processing kind of auditory cortical -- like all of that stuff is higher up, is not being picked up by the auditory brain stem response. But it is a good estimate for where thresholds would be, where someone might be raising their hand. And also you can look at it, and depending on where these wave forms are occurring you can go "Oh, that's a conductive hearing loss, or that's a sensorineural hearing loss." Adam: Wow! Kate: So this is Kate. I had a question. So, if a child for whatever reason, I'm think typically an older child, medically fragile, they're reluctant to sedate, is there any other test that can be done to give you some basic information, about what's going on? Especially if the child is not able to really participate actively in the evaluation. Lisa: There are acoustic emissions that I mentioned before are a good screening tool for that. So, if they -- if you're able to get otoacoustic emissions, which take a lot shorter time than ABR, you can -- it's a good suggestion that things are okay. I say that because, there are people in which you may see great otoacoustic emissions and a really lousy ABR, because what's happening, where the pathology is is actually passed where the otoacoustic emissions are measuring. But otoacoustic emissions are really a great screening tool and for most people, if you have big, beautiful, otoacoustic emissions, that's a good indication that things are looking good. Kate: So, you know, for your staff out there who are trying to determine if a child who's visually impaired and multiply impaired and maybe medically fragile on top of that, has problems with hearing, a first step, if there are issues about sedating the child for an ABR, is to ask for an OAE to be done? Lisa: Yeah. And if there's any way they can try to get some kind of behavioral testing that might be a good indication. You might be able to get... enough... to make you either feel that yeah, we really need to sedate and get a full picture or, well, you know, this looks pretty good. Maybe we'll come back in a couple of months -- next on month and see if we can add to this picture. So... you know... Kate: So maybe an OAE with some real good interview with the family about what the child seems to respond to, and some functional kinds of informal testing, where you just try out different signs in a comfortable setting, a quiet setting and see what kinds of responses you might get? Lisa: I think that would be it. Yeah, that makes sense to me for a first step. I wouldn't want to draw it out. If there's really concern about hearing, I mean -- Kate: You have to go for it. [laughter] Lisa: But, yeah, exactly. But I think it's worth -- I think sometimes we jump to auditory brain stem response, and for good reason, it's great information; and you know... but... but, you know, it is more invasive. So maybe we're assuming, "Oh, he's not going to be able to do that. Let's just do an ABR." Well maybe... Kate: Yeah, maybe... Lisa: [ Inaudible ] Kate: And I do -- I think where we see it most often, in my experience, are with those kids that have a lot of medical issues, and, you know, for very good reason the family, the physician is reluctant to sedate unless they absolutely have to. So it's like well, you know, in my mind you don't just blow off and assume the child's hearing. You have to do something to sort of establish that. Lisa: Right. And they don't have to be sedated. They have to be still, but they don't have to be sedated. [laughter]. So we've done it with sleep deprivation. You know, we really did. We kept him up. His poor parents had to keep him up all night and that kid walked in, and was just out cold, and we did it because we didn't want to sedate. So, you know, you get creative and then ‑‑ Adam: Sort of a natural sedation. [ Laughter ] Chris: Devious. Adam: Do you mind if we move on a little bit? Lisa: No. Adam: We touched on pure tone a little bit and the speech thresholds. But if you would go -- because this is the one that I think people are most familiar with. [ Start slide: ] and I think it's also the one that is kind of -- in my experience, it's been the one that's kind of the trickiest one to test because it's the hardest one to verify the authenticity of the response. [ End slide: ] Lisa: It really is. And with the pure tones we're not just trying to get the student to respond to a beep. We're trying to get them to respond to a beep that is just barely audible. So it's a really, really soft sound that we're hoping to get some -- the student to respond consistently to. And that's a reason, too, why we do some of the speech -- the speech threshold testing. If I put a student in the sound booth, and I say the word "baseball" or "Show me a picture of the baseball" or "Where is your nose?" or even I'm making a sound, "Bup, bup, bup," and they look up. I'm getting information -- the stimulus is more interesting to the student so when I get that speech test information, I should be able to hold that up next to where they responded to the tones and they should line up. They should be about the same. If they're not and that happens a lot with kids. It's like wow, they repeated baseball back to me at 10 decibels, but they didn't drop the block in the bucket until I was at 40. I know that something is not right with the reliability of one of those pieces of information is not correct. And that's why it's so important for this whole big battery of tests, which take a long time and it requires that the student stick with it for a long time because there's not one quick thing that can tell us everything we need to know, but also tell us if the response that we got wasn't just a false positive or is a good guess, or maybe I got into a pattern of when I was presenting the tone and the kid is like okay, I just raise my hand every five seconds and she looks happy. So, you know, you have to have something to be able to compare so that you can say, "Okay, yes, this is what's going on" or "I need to check something." Adam: Or, I think that one is is hard too with a kid who has a visual impairment because they're not going to be able to -- especially the speech threshold, because they don't have the ability to localize speech the way a typically sighted kid would be able to. So they're not going to know where to look for you and that might impact their ability to respond in the way that you might typically see. Lisa: As you were talking I was thinking of a student I had a few years ago who had deafblindness and they were convinced this kid had a really big hearing loss, but they didn't have really good test information, so he was going to go back for further testing. And they asked me to go and try to work with him to get him ready for the testing. And he was not going to raise his hand when he heard the beep. But the thing that I thought was so interesting and... I think an indication of what was going on with his hearing is, he was non‑verbal. He would sit at the desk and if I drummed my fingers on the desk and went like across the desk, he would laugh. So it was really funny. Like this thing was going across the desk. So I looked at the audiogram and I'm going this -- he should not be responding to that sound. And he would like -- he would grab my hand. He could figure out where my hand was and put my hand on top of it and laugh. So I think, you know, I think -- you know, that piece of information to go back to the beginning about -- if I had been the audiologist receiving him at the doctor's office or the audiology office and said listen, when I tap my finger he responds to that, that would be a nice piece of information for me to have, but also, just behaviorally, like he kind of liked it to play this auditory game. He thought it was funny and fun. Like how could I turn that into -- how can I use that to my advantage to get testing? So I think, yeah, ‑‑ Adam: That's one of the things that I -- I think all of us who work, you know, with kids and the TVIs who work with kids who are deafblind know to find those little games like that or little things that the kids like, and turn it into a game that we can practice so that when we go into the audiological booth and the sound booth. [ Start slide: ] Which is really weird, there's something that they're familiar with and we have kind of a little interaction that they enjoy. [ End slide: ] And then the audiologist can just sit and observe what we're doing and kind of, you know -- because sometimes, you know, it might be something that you can recreate, but sometimes it might just be something that they're only comfortable doing with that one person. Lisa: Right. And having another person there -- I can tell you, I worked in a pediatric ear, nose and throat practice for five years and I was the only audiologist there. So when a kid came in, it was me and maybe the parent would be helpful and maybe not. [ laughter ] Maybe they would be sitting in the booth and when Johnny didn't respond, mom would go try to prompt him. [ laughter ] "No, no..." But, you know, to have someone who is familiar -- I was like I'd put the headphones on and run out the booth and I'd sit down and the headphones would be off. [ laughter ] So I think having a set of hands would be helpful to me, but also to ease that kid's discomfort with this weird situation. It's uncomfortable -- not physically uncomfortable, but, you know... it's stressful! Adam: It is. [ multiple voices ] Chris: "I've never been to a place like this!" Adam: And the sound booth, especially, is really... Kate: It's strange. Adam: Yeah, like it just -- it feels different. You can feel it when you walk in there. Lisa: The door closes and wooop! [ laughter ] Adam: Yeah, it kind of like takes all the pressure out of the room, and so you're sitting in a room that doesn't feel like a room, and you're kind of unsure how big it is, And it's not a very big room, but, you know... Kate: And there's hardly ever any time to explore it in advance. Lisa: No. Because there's three people waiting! [ multiple voices ] Chapter 4. Collaboration with Audiologist Kate: I have one comment I'd just like to throw in, this is Kate -- based on some stuff that Adam was saying about -- you were talking about getting games going with kids that are deafblind so they can respond better. I was going to say it's also really important to do with kids that are not identified as deafblind, but that are visually impaired, because a lot of our visually impaired students may have hearing loss that is going undetected because it's mild or it's moderate. They respond to their name, or a cabinet closing and we say, "Well, they hear fine." But... but I think... that infusing auditory skills into activities for those kids, as well, can help us clue in on how well their hearing is going. And when our TVIs are doing their LMA, you know, then one of the things we need to be thinking about when we're talking about testing that needs to happen for our visually impaired, multiply impaired student, "Is have we assessed their hearing at all?" Because that does not automatically happen. And that's a real important thing for the TVIs -- because they're often times going to be the only one who has that inroad, through their LMA, of saying, "Gee, I'm not sure how this kid is hearing, and hmm, I don't see anything in the records about auditory testing have been done. Maybe we should add that to their comprehensive assessment and really look at that." Lisa: You know, I can just think of when I was in the medical setting, you know, I rarely got information -- Well, it depends. If the family actually was coming through me first -- when I worked in an audiology clinic and I sat down and got a history with the family, I... would know a little bit more about that student. And let's say there's a vision impairment -- as I went into testing. When you're in a medical setting, what usually happens, or at least my experience when I was there, was they went kind of through the nurse and the physician first. So now they show up at my door, and I don't know anything about the history. And I may be in a hurry or I just need to get the hearing test quick, and I'm looking at it, and I may not know anything about the child's vision. So let's say I go in -- I'm just thinking about -- I think the first time I got a student who clearly had a visual impairment, and who knows how many had one before that [ laughter ] that I didn't know, but this one clearly did. And I go sit down and I'm like I've got my routine that I do, and then all of a sudden, I'm like, "Wait a minute. How am I going to do VRA?" Because I had gone through my other -- that's the Visual Reinforce Auditory -- where they turn and look to the bear. I'd used all my other guns and they didn't work, so I'm holding on to my last one, my VRA and then I'm like -- Chris: I've got my bear in my hand. Lisa: and I'm, "We're breaking out the bear and box now" And then I was like, "Wait, hold on." And who knows? Maybe that student -- I knew nothing about their vision. Right? Maybe that student -- maybe the VRA would have been okay. It's a box that lights up, and maybe we all get real excited that there's a light over there. Maybe that's enough. But I really had no idea what that student's vision was doing the test -- I'm kind of winging it just trying to see. And so I think that's a really important piece of information. And I think it came up -- I hesitate to say this because, it scares me to think about too much, but I was going to say, it came up so infrequently that a student had a vision loss. Well, who knows? [ multiple voices ] Now that I think back, it may have come up a whole lot more than I realized, and I assumed they're vision was okay when I was trying to do all these different types of tests. So, that in itself would have been a really important piece of information. Adam: Well, yeah, I think that's one of the reasons that we wanted to bring you in here today was to talk about how important it is to bring as much information into the audiological as possible, and also to provide people with information about hearing issues. That's why we're doing this whole thing. And because -- so many times if a kid has a visual impairment, you know, like Kate was saying, they might have a mild hearing loss, but it might -- you know, they might respond to certain -- they might respond better than you think that they are just because they're tuned in to listening for certain things. And so their hearing might actually not be as good as we think it is. Lisa: Right. And this is true of all kids no matter what their vision is. I think that people have kind of a black and white idea about what it means to have a hearing loss. You either hear it or you don't hear it. Probably the same thing is true on how people think who don't know very much about vision. You're blind or you're sighted, you know. But I think what happens is I have students all the time who is hearing for certain sounds is excellent, but their hearing for other sounds is there's a significant hearing loss. And what that looks like to the teachers -- I've had people tell me this all the time when I'm going and trying to get the students to wear the hearing aids or the FM system and the teacher says, "He hears me just fine. Yesterday he was on the other side of the room and I called his name and he turned." And I'm like, "Okay. He heard the vowel sounds of his familiar name. He did not hear any of the consonant sounds." So I think that -- I think that people -- and it's understandable. They're using what they see, the responses of what they see, to make a global statement about what they think hearing is. So, I think that, yeah, a knowledge that -- or even like a kid that has a speech delay. "Well, it seemed like he turned to soft sounds, but he can't pronounce all these high frequency sounds. He's dropping off." You know, okay, is that hearing? That may just be articulation in isolation, but it could be hearing. So you really need to be aware of that. Chapter 5. Strategies to Prepare for Testing Adam: And we just have like one minute left. So I'm just going to finish up here by talking about -- we talked a lot about preparing or -- not a lot, but we talked some about preparing how to kind of things that we can do to help kids get ready for the testing. But I also want to touch on experience books just very quickly at the end, [ Start slide: ] to talk about, because I think it's important for students to be able to remember the experience even if it's not positive. Being able to talk about it will help them work through the emotions that they had during that experience. [ End slide: ] Adam: And the more you're able to practice that with them. Then the next time they go to the audiologist they might be able to be a little bit calmer. They'll know what's coming. They'll be able to anticipate it a little bit better, and you might be able to do a little bit more of that testing for a little bit longer. And there's an article that Kate sent with the handout that talks about that, and I think modeling is one thing that I've done a lot with kids that has helped, and just letting somebody come in and even if it's not really an audiologist, but a school nurse or something, and do a pretend exam on me while the student is able to tactilely explore the things in my ears and watch my responses to the auditory stimulus. And then, when we practice that it helps them then when we go to the audiologist, they're like, oh, I remember this. This is what Adam did. Lisa: Absolutely. Kate: And also along with that, is sort of doing some role play and letting them be the audiologist and put things in your ears. Be brave. But having that ability to be in the doing side of it makes them often times a little bit more confident when you're on the receiving side of it. Lisa: I'm doing this right now with this student. In one of my districts we have to make new parts of his hearing aid where we have to actually squirt something into his ear. And he had been told many times -- and good intentions -- that things aren't going to hurt. So of course, we go to do this and we're saying it's not going to hurt, and he's like, "Yeah right, I've heard that before." Even though it really isn't going to hurt. But somebody else told him before his shot that it wasn't going to hurt. So he doesn't believe it. Adam: And it might hurt, to him. Lisa: Well that's a good point. Adam: For him it might be painful. Lisa: That's a good point. But we've gone -- I've seen him now like three times just trying to -- so now he knows me and we're making little -- we'll get it eventually, but little steps. Chris: Twinkle says, this maybe for another webinar, but how can we assist our students with multiple impairments participate more actively in an evaluation, especially AI? I caught the part about practice... any other strategies? Adam: Well one of the things that I have done, in the past, with students who... are non-verbal or who are deafblind, is... we just practice calming routines with them that we can do with them, like in a booth. Like... we've done hand lotion, things that are portable like that, that are really easy to bring with you. And actually it sounds kind of -- it doesn't work with everybody, but I had one student who really liked deep pressure. And so we would wrap him up and just squeeze him, and he was able to tolerate us doing the -- you know, putting the things in his ears when he had that sense of being wrapped up and had that deep pressure. Chris: And feeling of safety. Adam: And that's what made him feel safe. And so he let up put things in his ears. And... and I had another student that we would countdown, when we had to do ear molds with him. There's like this -- I don't know it's kind of a foam that they squirt in your ear, and it's really, really -- it feels really weird, it's cold and kind of slimy. Oh, and before that they have to put a piece of foam in your ear. And so, -- and it takes awhile, but we were able to figure out how much time it took and we just counted down from that time, and as long he was able to count with us, and he knew how long it was going to be, then he was -- he would count really, really loud, especially the closer it got to one. [ laughter ] But that helped him be able to tolerate those things. Chris: And I know for me, with some of my students, if you have an audiologist who can accommodate this, you started about going into the sound booth and playing and exploring, and sometimes the audiologists could clear enough space for us, so that we could go in there so we can and just kind of hang out and explore stuff and bring some favorite toys. And then sometimes, like you said, too, Lisa, it didn't always help, but sometimes it was really helpful if the parents could go, or another familiar person. Kate: Well, another thing that we used to do a lot with the kids who were deaf and multiply impaired, to just sort of get them to be more comfortable and to get them to be more participatory, we would do a lot of games with listening to music; because we would find their favorite music and we would use that, and help them learn to be... you know, to show some sort of response. And we would -- put the earphones on and we'd sit there, and we'd just randomly start the music, and when they heard it, they were -- they let us know -- we would reward them in some way. And the other thing to, now, a lot of kids, you know, may not be using the big clunky headsets, they use the earbuds. And if -- especially family's may use try using earbuds, maybe just on one ear to start out with, some nice music that their child really loves, at a soft level, just for a short time, just to to listen to it for a short time, and getting them used to having something going into that ear, because often times, one of the harder things, is just having something in your ear. [ multiple voices ] Chris: Well Adam, didn't you -- See I can never remember all of the details of this, I just have bits and pieces -- but didn't you do a video for one of your student's with vision, about -- and you were playing the part of a student going to the audiologist? Adam: Yes. Lisa: That's great. Chris: It was awesome. [ Laughter ] Adam: And that -- It was sort of like an experience book, but it was like, "The trip to the audiologist," you know, and... Edgenie: You need to share that one. [ multiple voices ] Adam: I think it has gotten lost at some point. [ multiple voices ] Kate: In smaller towns where people may not have great audiological suites, or whatever, there is often times someone who distributes hearing aides, or whatever, and if you can form a relationship with them where you can go in, maybe towards the end of the day, or at a time where you are not busy, and just have a visit, and do some playing there. You know, that, often times, is another way, especially in a smaller town, or an area where there's not a university with a nice suite of sound equipment [ laughter ], to get that child that experience. [ bottle top squeals ] But even if you have to just do things, like going into a room, where it's small and it's darker, and you're going to sit and you're going to put that -- playing audiologist, and doing it a lot before you ever get around to going. Adam: Yeah, one of the other things I have done is -- I did with one of my kids was, we used to play a game where we would... where we would play a tone, and then I would repeat it, and then he would search for it in my voice, and then we would find it together, like coming out of the speaker. So he would have to search for the sound source when we heard it; to get him used to, kind of like, instinctively looking around for the sound, and you know, that was... that was a way of kind of helping him to learn that, you know, that the sound was... that there... to help him try and localize basically. Lisa: Yeah, and when you said that, the repeat back thing; I mean, you know, the kids that are echolalic, I mean, you know instead of trying to teach them another task of "You hear it, now you have to do this." I mean,"You hear it and you echo it back." So, I would have kids going, "beep", and "Okay you heard a little beep." So... so, you know, just trying to figure out what it is. Adam: Yeah. Lisa: You know, back when I was in graduate school -- they don't use this thing anymore, but it was -- I loved it. I don't know why they stopped using it, but it shot out M&M's every time you pressed... [ Laughter ] Lisa: So the audiologist had the control, so if the kid hit a false positive -- they'd hit the button, and you could make sure that no M&M came out. But when they did it right, they'd push it and the M&M came out. And I know that's... [ inaudible ] worked really well. [ Laughter ] Kate: Twinkle says, "Is there a list, ideas et cetera, about -- with good tips for how -- for the TVI, AI, Perkins collaboration for assessing the child after the audiological?" Adam: That' s a great question. Lisa: That's a really good question. Edgenie: Looks like a great [ inaudible ] [ laughter ] Chris: Twinkle, I wonder if could -- cause that is a huge can of worms, but it is something I am personally very interested in. Edgenie: Isn't Robbie and a team kind of working on this? Chris: I kind of wonder if we can put on to another webinar, Twinkle? And have that really be a broader, in-depth topic. Adam: Yeah, yeah. Kate: And there's even a product. Edgenie: I really do believe it is on the priority list. Adam: It is. Yeah, Robbie is, in fact working with... Chris: I wasn't going to put that on Robbie's shoulders, but we're working on it Twinkle. Edgenie: Right. Is Robbie off the call, maybe she could ask her. Kate: She's off. Edgenie: She's off. [ Laughter ] Edgenie: You all maybe, this is Edgenie, you may also be interested in knowing that this past weekend was SWOMA here at TSBVI, and Lisa, and Robbie Blaha, and Chris Tabb did a remarkable -- I mean it was fabulous presentation on how to work together as a team in evaluating the individual with deafblindness, their ability to hear environmental sounds, and use it as part of their orientation and mobility training. And, I believe. from that, has grown a work group that is going to be looking at developing some projects and some guidelines, perhaps, on how to work together to get this important information. Lisa: I think that so many times as a clinical audiologist you do not see folks outside of the clinic. So, all this really important information, arguably as important as what you get in the sound suite, is missed. And I don't know that -- I can only speak for myself. I can say that I wasn't even really asking for it. I was so focused on, you know, what -- the clinical audiology -- what I learned about how to be a good clinician in that setting; that I didn't even know to ask for information outside, other than what I would maybe ask the parent, and depending on how good historians they were, I would get that. And so, what we mentioned at SWOMA, is that... I... I feel like there's so many people out working with these students that have this really important information and maybe audiologists that don't even know to ask. So rather than waiting for the audiologist to think, "Well, gosh, maybe I should ask the VI teacher -- they may not even know that the VI teacher is working with -- or an O&M instructor -- I didn't even know what an O&M instructor was until I started working in education audiology; never even heard of that field when I was in the clinical setting, and wouldn't have know to even ask to talk to that person. So, I think... if people can, kind of just give this information -- if a little report came, even if the individual from the school could come and said, "This is how this child behaves in school to sound and this is what I've seen; it would have been so lovely, but I never... thought to ask for it, or went looking for it outside what happens... Adam: And it seems kind of like it's instinctive, that you would have it, but yeah... there's nothing there... [ Laughter ] Chris: That's what we're relying on you for. [ Laughter ] Kate: Okay, I think it's a wrap. [ multiple voices ] [ Start slide: ] [ Music ] [ End slide: ]