>> Kathy Hurst: Good afternoon. Welcome to our first in a series of four of our special broadcasts this year on hearing issues for students with deafblindness. I am so pleased that we're doing this and I'm very excited that we are co-sponsoring this event with Texas School for the Deaf Education Resource Center on Deafness. We really appreciate their support and are glad that they're here to help us as we bring the series to you guys. We have two wonderful guests, wonderful facilitators for this series, Chris Montgomery and Adam Graves who are both educational consultants with the Outreach team; and I'm going to turn it over to them because I know they have a lot of territory to cover today.  >> Chris Montgomery: Hi everybody. My name is Chris Montgomery and as Kate said I'm a deafblind educational specialist here with the Deafblind Project and Outreach at Texas School for the Blind and Visually Impaired. It's quite a mouth full. My job is primarily working with deafblind children and their families. We do -- if you're not familiar with Outreach we do training, onsite technical assistance among lots of other things. My compadre here is -- >> Adam Graves: I'm Adam Graves and I do most of the same things that Chris does here with the Outreach Department at Texas School for the Blind; and I also -- my mother was an audiologist so this is a topic that interested me, so that's why I am here.  >> Montgomery: We tried to get your mom on board here today but she wasn't available. For this study group we're going to try to focus, really, on hearing issues, but really from a deafblind perspective so that a student with deafblindness who has the combined sensory loss of vision and hearing. We're going to try to look at some strategies from the hearing side of things, and we hope that information that we provide will be wide ranging so that you can get some questions answered about your specific student, or your child, if there are any parents who are tuning in today. As we get further into the series there's going to be lots of other topics covered and we already had a request to maybe put those training dates back up again if we could. So we'll try to do that. And if we're not making any sense, or -- which is very hopefully unlikely, but if you have any questions please feel free to ask them and you can do that by pressing Star 6 which will unmute your phone and you can just bust in and ask us your question or you see the chat box that's in the bottom right hand side of the screen and you can type in your questions there and we will try to answer those as we go but do keep in mind that this is going to be an ongoing series. Today is primarily Hearing 101 and getting our kids ready for that otological stuff, so there'll be deeper and broader topics covered as we go along. Some other things that we're going to look at is the law in brief and that would be for an auditory impairment or a student with deafblindness, ear anatomy, types of hearing loss and preparing, as I said, our student with deafblindness for an otological visit. And we're also going to be looking at a couple of short video clips along the way. So strap in and we hope that we cover anything you might have ever wondered about. So looking at our next slide auditory impairments what are the requirements for an auditory impairment? You can see that it is based on primarily on educational need, and it's also a very important thing that it is part of the ARD process. So looking at number one, the audiological eval needs to include a description of the implications of the hearing loss for a student in a variety of settings and circumstances; and that would be with amplification -- the recommended amplification and without recommended amplification. And hopefully this is going to give us a good idea of real world auditory functioning. You see there also that it must include an otological, an ENT report ,so it's really best practice that an actual ear, nose and throat doctor does that evaluation. They're going have a lot more expertise, and they're going to understand the conditions and the backgrounds of the hearing system better than any other doctor. Just to clarify that, there is a clause that says, if an ENT is not available you can use a pediatrician, but it's really best practice to use that ENT. Some other things to mention, and we're not going to go too far into it today, but anytime that it's possible to get the team to do a functional hearing eval, that can give you lots of really good information, again for that kind of real world hearing stuff. But just be aware, again this is sort of the deafblindness side of things; most of these functional hearing inventories are going to be for kids with vision, so you're going to have to the adapt anything that's visual for a student who may have low vision or no vision. And you can see... down there at the bottom, we've got a link to the Region 18 framework, and you can go there for all of these laws and everything that we talk about today for a detailed descriptions.  ^M00:06:28>>So you guys can see we've got a poll up, and let you guys vote on that. You can see what a student with low vision and unilateral hearing loss be eligible as deafblind so I wonder what our next slide is going to be about? Okay, so we just looked at what the requirements are for an auditory impairment and this is going to be the requirements for deafblindness. And you can see we've got four points here basically, and a student can qualify for eligibility for deafblindness for any one of these points. The first one is pretty easy, right? If you meet the eligibility for both hearing and visual impairment, you meet the criteria for deafblindness. The second one needs a little bit of... some verbiage behind it I guess. On this one you might have a student with a suspected hearing loss, and what needs to happen is that a speech language pathologist would need to do a report. And for that student with a suspected hearing loss, why aren't they talking yet? And so that speech language path would do their assessment and try to give some understanding in that report of what's going on there and why that student without any kind of hearing impairment if it's suspected, why aren't they talking yet. Number three, this is the one where I think where I personally see a lot of confusion, and that's the concomitant loss, so combined loss of hearing and vision. And look at the very last few words, 'educational performance.' So you might have a student that on their own would not meet the requirements for a vision loss or on its own may not meet the requirements for an auditory impairment, but if you combine those two and if they affect educational performance, they would meet that concomitant loss -- that combined loss. They would meet the requirements for deafblindness. >> Hurst: Chris I have an example. I just took a call today from a parent whose child has Charge Syndrome, was profoundly deaf, but the vision loss was a little shaky. There wasn't a lot of involvement in terms of the [inaudible], as far as any retinal stuff, that they knew of, but there was problems with glare and light and things like that; and so the parent is sort of trying to figure it out. And that was the part I stressed to him, that it was the ARD committee's responsibility to assess and determine if any of those problems that he's having with glare and sunlight and stuff like that, are affecting him in any way in his educational performance; and it's tricky. >> Montgomery: It is tricky and I think you said -- something that I didn't say that's really important is that it is an ARD committee decision. So, a lot of these kids can be really complicated, and so it takes a team coming together and expertise across different areas vision, hearing, speech, all these people to kind of come together to really try to make an informed decision on this. And that sounds very much like a student who I just saw with Charge Syndrome, who had pretty darn good vision, but it's things like glare, things that a typical hard of hearing or deaf student may be able to look across the room and see, that that kid with the vision problem might not pick up. And we're going to talk a whole lot about that in a minute. Number four on this list real quick. You've got a student with a medical diagnosis of a progressive medical condition, and... the big one there I think would probably be an Usher Syndrome diagnosis. And that's something that RP -- retinitis pigmentosa -- I can never pronounce this. You know their vision is going to be pretty decent as a youngster, but it's not until they get into their teen-age years and on up that it's going to start to be -- start causing problems, when you'll start to see that. Okay. What do our poll results show? Again it's, 'Would a student with a low vision and a unilateral hearing loss be eligible as deafblind?' We have a 63 percent response rate that says yes, a bunch of maybes, three nos. Does anybody have any ideas here in the room or do you want to queue in on the line here?  >> Hurst: Chris, I think it's a maybe.  >> Montgomery: Why do you think it's a maybe Kate?  >> Hurst: Well, because I think that you really need to look at what the impact of that unilateral hearing loss is in a lot of situations. If they have very low vision, or even just moderately low vision and they're in a group setting and they're trying to follow a conversation, it may have some impact. I don't know. It might have some impact in their ability to travel safely. I don't know, and again that's why I think--  >> Montgomery: It could be glare from the overhead that teacher puts up.  >> Hurst: It might be a lot of different things. And I think that's what makes it so tricky for us when we're looking at kids with combined vision and hearing loss, because like you say, you take the vision, not that big of a deal. You take the hearing, not that big of a deal, but you put the two together, and unless, as a team you're really looking at all the details of possible impact in their educational performance -- you don't know whether they should be labeled deafblind or not. That's my vote. >> Montgomery: Yep, I think you're right Kate. Let's go with... Let's go with the definite maybe. [Laughter] What have we got for the next slide Adam?  ^M00:12:54>> Graves: Auditory impairment. >> Montgomery: Okay, so this has a bunch of animations. So we've got auditory impairment versus deafblindness. And... what's going on here is so there might be some areas when we get this audiological report -- that the audiologist really is starting to look at what are some of the main differences between a student with deafblindness -- that combined or concomitant loss -- versus just your typical student with hearing loss or deafness? So you can see an inability of speech read, difficulty seeing facial expressions or body language, difficulty in seeing sound sources. These are things that a typical deaf student or student that's hard of hearing may have no trouble with, but if you again overlay that visual impairment, or a problem with the vision, it's a whole different ball game. We talk about incidental learning, and so much of your learning is incidental learning. I can look across the room here, and you guys can't see her, but I can see Edgenie biting her fingernails. She looks bored. That means that I need to pick up my pace. If I have a vision problem I may not be able to see that. Just one more point here with our environmental sounds. This is another sort of incidental type of learning thing. When we hear a sound we can turn and look where that sound source is coming from. A student with a vision loss, typically he's not going to do that, right? They may tune that sound out because there's no connection visually, all stuff to really look at. Continue along this best practices talk here. ^M00:15:16>>So you can see how it's very important to consider both the vision and the hearing together. To elaborate a little bit further on this point, so it's identification of a speaker or sound source both near and distance types; and let's look at the lighting too. All of these points, you can see, take into account what's the lighting in that situation? Okay, let's take the next one.  ^M00:15:48>> So we talked a little bit about individual sort of deafblind are not incidental learners. The best practice for a student who is deafblind is to include a VI teacher or a teacher of the deafblind to consult with a teacher of the deaf and hard of hearing, and an audiologist when writing those implications on the hearing loss. And I didn't really hit this hard enough, so I want to kind of go back and talk about this. In the audiological report, the audiologist should write implications for what this hearing loss is going to be; and again, that's going to be in a real world situation with and without amplification, and so what this is saying is that practice is really going to be if there's a possibility for those other teachers to come back and look at that, and then collaborate on that going forward. What does this mean when we combine that vision loss with that hearing loss? Conversely -- I'll just say this too. It might be really nice for the teacher of deaf and hard of hearing or the teacher of the deafblind if they can collaborate with the VI teacher on writing a functional vision Learning Media Assessment. Again, like using that team for it's expertise that's available. ^M00:17:11>> I'm talking a lot at the beginning and I swear Adam's going to talk in just a second. So let's look at sound and the perception of speech and what is sound? So... I'm visual I guess so I have to kind of think of this in a visual way, and so the picture that I have is if you're at a clear pond and you toss that pebble in and you have those concentric rings that go out in the water. If I relate that to sound waves -- obviously you can't see sound -- but they are vibrations in the air that move at different frequencies. The closer you are to that pebble being tossed in there, or that sound source, the louder it's going to be. And the loudness is going to be measured in amplitude which is the same thing as decibels. So you'll see that a lot, like it's a little D big B which means decibel which means amplitude or loudness. The closer those waves are together the higher pitched the frequency will be and so the frequency is just -- it's not how fast the sound moves, but it's how close the sound waves are together.  ^M00:18:30>> Let's look at some hearing terms here. So you can see unilateral and bilateral, and unilateral means one ear. So a student may have, maybe an unimpaired or have a mild loss in one ear and then show a significant hearing loss in the other. Bilateral is kind of the opposite. You've got a hearing loss in both ears. You can see 'stable, fluctuating and progressive,' that's pretty easy to understand. That's a hearing loss that stays the same; and we're going to go into more detail on this later. I'm just throwing these terms out. 'Fluctuating' is going to be, it changes from day-to-day or maybe within the day and 'progressive.' We talked about that too. That might be a student who has a condition that might make them lose their hearing over time. We have got 'flat, sloping and cookie bite.' I like 'cookie bite.' So that's going to be when you're looking at an audiogram -- and we're going to look at one and look at more than one in a moment -- but you'll see that when they map a person's hearing, that can be 'flat,' like straight across. It can be 'sloping.' If it's 'sloping' on either side that would show that they've got a lower or upper frequency loss and the 'cookie bite' is going to look just like it sounds, like somebody -- sort of a smile. Then that would mean that they have a mid-frequency hearing loss. There's 'mild, moderate, severe and profound' and those are degrees of hearing loss. Cochlear and retrocochlear are hearing loss before or after the cochlea.  ^M00:20:14>> I think we have another poll to pull up Adam. Do we?  >> Hurst: Before we go to this poll we're getting some great comments and questions over in the chat; and one I want to throw out to the whole group and let people expound on it. Angela mentions... that they have a hard time getting audiologists to test with or without amplification, and is it required?  >> Montgomery: That's a very good question. The best practices are that it's required, yes but I don't -- >> Hurst: I think that in the definition for eligibility it clearly states 'with and without.'  >> Graves: Yes, it is required.  >> Hurst: So I would say it is, and this is just me, and Robbie Blaha I know you're out in there somewhere, so please weigh in. But it is my understanding that you need both aided and unaided results. >> Montgomery: And I agree Angela. I see many audiological reports that I try to decipher, the scribbles that are on there, that do not test for both aided and unaided. So that seems common to me too.  ^M00:21:25>> Any other ideas or does anybody else want to weigh in on that? If you press Star 6 you'll unmute yourself and you can talk to the group. It's a two way street people. Come on.  >> Edgenie Bellah: Well this is Edgenie Bellah and I'm in the room with Chris and Adam and Kate. I believe last year there was an incredible, I'm not sure if it was a TETN case or a webinar where we brought in an audiologist who talked about the importance of testing and making sure that the audiologist is aware that it's important that the hearing aid is set in such a way that it will pick up environmental sounds and not muted for lack of a better description. So I would encourage you, I don't know if we have that recorded. >> Hurst: Actually our very next webinar we're going to have that same audiologist back talking about that, so that was a really nice plug for our next webinar.  >> Bellah: And I was not paid for that. >> Montgomery: And I would say, too, when you guys have questions like that go into the legal framework at the Region 18 and looking through that -- under eligibility -- you can see there is eligibility for VI, for AI, for deafblindness and you can see the law. It will spell it right out.  >> Hurst: Well, and for me, as a Deaf Ed teacher I've got to know what a child can hear with an aid or without, because even cochlear implants fail to function at times. Especially if the kid has jerked the little receiver off and thrown it down the toilet. It does happen, so it's real important when we're talking about educational functioning, what are we going to do that day when that hearing aid got lost on the bus, or it got thrown down the toilet or whatever? We've got to accommodate that child's need, or they might as well not have bothered to have come to school that day. So knowing and understanding the full impact of a child's hearing loss, especially if there's vision involved, that's just to me a real no-brainer.   ^M00:23:33>> Montgomery: Let's look at this next slide and this is an audiogram; and you can see also see that there is a red part and they call that the speech banana. It's sort of banana-shaped if you use your imagination, but that's where the typical range of speech would fall, and you can see the vowel and consonant sounds. If you look along -- left to right -- the X axis, I'm sorry, that's going to give you the frequency response. So to the left you'll see 125. That's your low frequencies. As you move up to 8,000 that will be your higher frequencies. Conversely, if you look from top to bottom, or along the Y axis, you're going to get louder in amplitude, or decibels, as you move down so you can see how something like water dripping is pretty quiet. We're at about 20 decibels and it's in the lower frequencies, about 125 hertz. You can also see that something like vowel sounds, speech are down low and kind of quiet too. Something that's really loud, like what is that? The jackhammer down there, that's going to be about 120 decibels, and again, that's going to be in the lower frequencies. So all that stuff that's louder than speech in the audiogram and we need to be aware that we have to have at least a 20 decibel signal to noise ratio. That means that your signal or person speaking needs to be 20 decibels louder than the background noise that's happening behind them or in the room. If you don't have that 20 decibel cushion that difference you're going to have a real hard time picking out -- if it's speech you're trying to listen to for instance -- out of that kind of soup of background noise and audio clutter. Okay that looks like we have a new poll up. So how might background noise impact the perception of speech? I think I just told you so let's see.  ^M00:25:59>> You want to flip to the next slide. We'll leave the poll up for a second. I think we'll be okay. Again you can see here, it's an audiogram and here we're looking at... different levels of hearing loss. So you can see normal hearing is zero decibel loss all the way down to about 25, and it's really like 25 to 40 you start to have a mild hearing loss. You can see the next one moderate. It is about 40 to about 55 decibels of loss; all the way down to profound which would be you've got to have a jackhammer beside you to hear it.  ^M00:26:47>> Okay, again here is the speech banana so you're looking at where speech falls... within that range of hearing loss. And that -- you can see at the bottom it says frequencies in cycles per second and that would be measured in hertz up to kilohertz; so 125 up to 8000. A typical person is going to hear -- or typical adult hearing is about 20 hertz at the low end up to about 15 hertz at the high -- or 15 kilohertz I am sorry at the high end. A kid who hasn't had any hearing loss yet should hear from 20 to 20; but as we get older we start to lose our higher frequencies, so you'll start to the develop high frequency hearing loss. You know I probably can't hear above 15,000 cycles anymore.  >> Hurst: I'm sure Chris because you're an old musician.  >> Montgomery: Tinnitus and all kinds of stuff have set in. Okay, I'm going to turn it over to Adam now.   ^M00:28:01>> Graves: All right I'm going to talk a little bit about the anatomy of the area and the different types of hearing loss. This is a diagram that shows the structures of the ear; and there's three basic sections of the ear. There's the outer ear, the middle ear and the inner ear. The outer ear is made up of the pinna or the earlobe which collects the sound, then it goes through the auditory canal to the eardrum, which is also called the tympanic membrane. And those are all the structures of the other ear. The inner ear is made up of the three tiny bones, the smallest bones in your body which are the malleus, the incus and the stapes also known as the hammer, anvil and stirrup; and there is a tube that runs -- the Eustachian tube that runs from the middle ear and it drains into the nose. And... and that's an area... if that Eustachian tube gets clogged that area can fill with fluid and cause some hearing loss. And then the inner ear is made up of the three semi-circular canals which help with balance; and then the cochlea which is where the sound is collected and it's attached to the cochlea nerve which runs to the brain and sends a sound signal from your ear to the brain. When all that is working correctly and you have an audiologist come in and take a picture of your ear or do an audiogram. They don't actually take a picture. They graph what you can hear and it looks something like this. This is an audiogram of someone with normal hearing and you can see that the area above the line there is the range of sounds that a person can't hear, and everything below that is what they can't hear. So obviously this is person who can hear normal speech in a normal range.  ^M00:30:37And there are four types of hearing loss. The first one -- they are conductive, sensorineural, mixed and auditory processing disorder. And I'm just going to go straight into conductive hearing loss, which is a loss that occurs as a result of damage or malformation of the outer and/or middle ear. And a lot of times those can be treated with surgery, since it is primarily a structural thing. And some of the causes of conductive hearing loss -- one of the most common causes are ear infections that cause the ear to fill with fluid in that middle ear, where those three bones are that we were talking about before. Also interference like a buildup of wax or beans in your ears; and a ruptured eardrum is another one that is pretty common.  >> Montgomery: Adam I wonder if you would mind talking a little bit about beans in your ears. People are probably wondering.  >> Graves: Well I've heard tell of there are occasionally are students or kids, maybe even adults-- >> Montgomery: Is that a clinical condition beans in the ear?  >> Adam Graves: I don't know if it's recognized by the American Medical Association, but it happens.  >> Hurst: Trust me. They've seen it. That and PlayDo and many other things, foreign objects.  >> Montgomery: Years ago we had a student who had this type of conductive loss due to a Cheetos. It was in a few weeks.  >> Graves: At least the Cheetos won't start sprouting. Allergy, a lot of people have conductive losses periodically due to allergies, and that would be a fluctuating hearing loss; and there are also genetic causes such as Stickler Syndrome or Treacher-Collins Syndrome that cause deformities of the canal. So just to remind you of the structures we're talking, about it's that outside of the ear, the pinna all the way to the ear drum.  ^M00:33:18>> And this is what an audiogram of someone who has a moderate hearing loss due to conductive hearing loss would... look like. You can see that there is -- if you look at the letters that fall below those lines, it's a lot of really low sounds... like vowel sounds like E and OO, the OO sound is in there and also N and M type sounds. ^M00:33:57>> Anything above that would be difficult to hear. Going back to Chris's talking about sound to noise ratio, in order for a person to be able to hear even those low frequency sounds you'd have to be able to speak 20 decibels above where that is; so that's at 40 decibels right now that that person would be able to hear so you'd have to be able to speak at least at 60 decibels for that person to hear normal sounds or normal speech.  >> Hurst: And this is Kate. I just have to throw in most of our classroom environments -- I can't remember maybe Robbie or some of the rest of you out there -- but there's some statistic where most of our classroom environments there is like a level of just general noise in the classroom that runs at about 70 decibels; and so that would be, for most of us it would be hard to hear things but for someone with a hearing impairment it would really be hard, and I think a lot of times we forget that amount of hearing loss becomes a lot more when you put it in a very noisy environment that's trying to pick up sounds. >> Montgomery: Cafeteria... >> Hurst: Cafeteria, gym, you know, >> Graves: Air conditioner...  >> Air conditioning, doorways are opened, there's noise down the hall, radiators -- you know, there are just so many things. And it really is something that we don't pay nearly enough attention to -- for all of our students -- but especially for those kiddos who have some kind of hearing impairment and vision loss combined.  >> Graves: Oh, yeah. >> Montgomery: Well, I know that even for us -- without even students in mind -- sometimes you're in an environment are where there's like a loud air conditioner or something running, and I wonder if people have had the experience of not even hearing it until it turns off; and suddenly you're like oh, my God that was loud. And so it's just really stuff to clue into it.  >> Hurst: Yeah, I think anything we can do to unclutter our auditory environments, the better for everybody involved. >> Montgomery: Okay, so looking at sensorineural hearing loss and so we're moving further inside the ear. And sensorineural hearing loss occurs when there's damage to the inner ear or the cochlea or the nerve pathways from the inner ear to the brain and most of the time a sensorineural loss cannot be medically or surgically corrected; and this is the most common type of a permanent hearing loss.  ^M00:36:44>> Obviously, sensorineural hearing loss is going to impact the ability to hear faint sounds, even when speech is loud enough to hear it still may be muffled or unclear. The most typical test that they would use to measure this kind of loss is a pure tone test; and as an aside, a newborn testing is going to be done with an OAE and that's going to be part of the hearing screening.  >> Hurst: Yeah, how many of you have seen that done where they take the baby and it's just a little non-evasive thing, a little probe, a quick test to can do a screening; and in Texas it's done on all newborns before they leave the hospital?  >> Montgomery: And OAE, by the way, stands for otoacoustic emissions, so a little puff of air goes in there, and they sort of measure that bounce back to see if that middle ear is functioning correctly.  ^M00:37:48>> Okay, if we go to the next slide which is just another beautiful Adam animation you can see that the part that's shaded in pink is going to be what's affected here. So you can see we're kind of -- again we're moving further back into the ear with this.  ^M00:38:11>> Some of the causes, diseases passed from the mother to child, illness when you're a child, a little baby anything from measles, meningitis, chicken pox, a prolonged type fever, treatment for cancer, or if there is impact to the head or the ear, there's a fall or accident or something, otoxicity and that might be caused by medications that were used to fight early childhood infections; and then there's genetic stuff too, like we mentioned Usher's Syndrome. A couple of other things that aren't listed on here, but that can cause sensorineural hearing loss, is a prolonged exposure to loud sounds. So Kate was teasing me earlier about my guitar playing. I actually have friends with tinnitus, and that's like they've gotten that from standing next to a drummer for a long time and that's like a ringing in your ears, and that's another thing that can happen. If you work around airplanes or something. Moving right along. ^M00:39:27>> Here we are looking at mixed hearing loss and I think Adam is going to talk about this.  >> Graves: I'll go ahead and talk about mixed hearing loss. Mixed hearing loss is exactly what it sounds like. It's a combination of conductive and sensorineural hearing loss. And the causes are generally some sort of combination of the causes of one of those two... things. So it would affect the entire ear, both the inner and middle ear, as well as the inner ear. And I'll go ahead and talk briefly about these handouts or about these audiograms. This is an audiogram of a mixed, high frequency hearing loss, and it's very similar to the one that we saw before, but this is a moderate hearing loss. And I think the last one was a mild hearing loss and -- so you can see that the amount of -- the degree of hearing loss is not as bad as -- you can hear things like a piano or a dog barking but there's still a lot of sounds, especially vowels or consonant sound, the Ss and the Fs that would be difficult for someone with this type of hearing loss to hear. This is an audiogram of someone who has a moderate conductive loss. This is a high frequency loss. You can see that this is kind of an odd looking audiogram. This is a person who has pretty good hearing up to about 2000 cycles and then their hearing drops off significantly. So very high frequency noises are going to be difficult for them to hear, and again it's those sounds like K and F and CH that are going to be hard for someone with this type of a loss to be able to perceive. This is an audiogram of a low frequency loss, and low frequency loss is pretty rare, so you probably won't see too many of these type of audiograms, but -- it's usually something that's -- usually the result of an infection which damages the middle ear or the retrocochlea or parts of the ear.  ^M00:42:29That's all I'm going to say about that. And then the fourth type of hearing loss is called auditory processing disorder,m or central auditory processing disorder. And this is when a person has the part of the brain that translates what the ear delivers does not function properly. And there's still a lot of -- we're still learning a lot about auditory processing. For someone who has -- it's difficult to detect because it won't show up on an audiogram because someone who has central auditory processing disorder will be able to hear pure tones, but they might have trouble hearing speech under normal circumstances or recognizing speech. And Kate you look like you have something to add.  ^M00:43:28>> Hurst: Well, I was just going to say with this one of the things -- I know we have a lot of people who are TVIs out in the audience -- and so one of the analogies that you can kind of work with to think about what is auditory processing disorder is. it's kind of similar to the way a cortical vision impairment works. The ear itself may be functioning just fine but the way the information that is coming into the area is processed by the brain isn't working so well; and there are other, numerous kinds of things we are finding out, that I know only names of and don't have real clarity of the difference. But there are things like auditory neuropathy and there's lots and lots out there right now, and hopefully when we get into, get our audiologist and some of those people who are really experts on this they can shed some more light on this for us. But I think for the layman, if we could just sort of think about it like we might think about cortical vision impairment. [Multiple speakers] We're getting the stuff in-- >> Montgomery: We're getting auditory clutter as well as visual clutter.  >> Hurst: Yes, absolutely... absolutely.  ^M00:44:41>> Montgomery: Okay let's talk a little bit about the difference between hearing and listening. And if you are not a person who is hard of hearing or deaf, hearing just happens. It comes to you whether you want it or not. Sometimes you actually might not want it. But it's a distance sense. If you're in range you're going to hear it. A deafblind person -- wait a minute, let me back up -- so listening though, is going to require conscious awareness. So you're going to have to concentrate to make meanings from words and from sentences. You're going to have to concentrate to put a sound source together with meaning; so a door slamming, you are going to have to correlate that sound to what that is. I hope that makes sense. So... a deafblind person might tune out some of these environmental sounds, because they don't have that visual reference to kind of put to that thing that they're hearing. They might hear it, but again just kind of tune it out because it's not something that -- it's almost like it's below their threshold. It has no meaning. Why am I going to pay attention to that? So that's another thing when we're looking at a deafblind person's hearing that's really important to take into consideration. Is -- they might actually be hearing something, but if it doesn't have meaning attached, they might not respond; and that's where auditory training would come into play.   ^M00:46:24>> Hurst: Yeah, I think that's a really important thing Chris, because if you don't see what is making the sound, if you can't touch what is making the sound, you may not know what that sound is all about. If you take it in and it scares you, that's all you know about it, or if it's something that catches your attention that may be all you know about it and so this is why it's really difficult to -- >> Montgomery: It's outside of arm's reach.  >> Hurst: It's outside of arm's reach, just like visual information.  >> Montgomery: for our students with deafblindness.  ^M00:46:57>> And I worked a really long time on this example. So who has ever had the experience -- and this again is putting vision together with hearing. Who's ever had the experience of contextual hearing? So maybe your significant other asks you if you, "Want a hot dog or a hamburger?" But you thought you heard, "Do you want a hot rod or hair dryer?" But you look -- and since for me it would be my wife -- she's holding like the Oscar Mayer wieners package -- I could put it together, that she said hot dog and not hot rod or hair dryer. She's not holding a crescent wrench and curlers, just to throw that out there. All right, so auditory development -- we're moving kind of fast you guys, but please if you've got -- we haven't had many questions, but ask them if you've got them. We will slow down and answer those.  ^M00:47:57>> So we look at this little kind of chart here. Phase A is really the attention to sounds and voices. It's the awareness of. So you can see some of the strategies -- speaking directly into the person's ear. So that's going to reduce that background noise and give you a much better signal to noise ratio. Obviously, common sense you don't want to talk too loud even if the person is hard of hearing. You might damage parts of that person's ear if you're like screaming in their ear. I usually try to pair something like these first things -- these cueing to listen, this response to sound, the stimulation for vocalizations and sounds, with a movement -- with something that's going to attach meaning to those sounds for my student. As you move into Phase B -- that's when you start to see recognition of sound sources. So you'll start to see increased vocalization from that person. You're going to see a person maybe turning toward a sound source, reaching out to locate that sound source.  ^M00:49:15>> If we go to our next slide, so this is going to be a typical hearing person's milestones; and you can see newborn, six months, etcetera, -- startles to sounds and starts to orient or look towards where the sound is coming from. And a deaf person too they can even compensate if they've got any sort of residual hearing, or if they're hard of hearing, they can obviously use their vision to scan the area, if they hear something in their environment. Our deafblind kids are not going to be able to do that.  ^M00:49:56>> This is an interesting slide I thought. You can see that it says, in the 1980s two studies found that children with a unilateral hearing impairment -- so that's one ear that is impaired -- were ten times more likely to repeat a grade compared to the general school-age population. Second bullet point, 406 children indicated that 54 percent -- that's over half -- were in special education when they had additional -- some level of audiological support. The thing is -- I think the point I really want to make here -- you can read that for yourself -- but that does not include that vision impairment laid on top of it.  ^M00:50:43>> So sound has meaning. Okay? We're just trying to put sound into context for our students who may be low vision or can't see; and again, I'm always trying to give them a real world situation; doing stuff within familiar routines. I want to have consistency in my vocalizations, not a bunch of clutter. I'm not going to chatter to my students. I'm going to try to keep my verbalizations really on point, concise and with meaning.   ^M00:51:18>> Hurst: Guys, I hate to cut this off but we have to stop at 4 o'clock, and I know there's a little bit more we want to cover -- but I think we'll be able to bring a lot of that up especially about preparing to visit the audiologist. We'll have time to get into that more at our next webinar, so I hope you will join us for that. That will be in November. And we are so glad that you were able to join us. Don't forget your evaluation online. Adam, Chris thanks for all your hard work in putting this together. Everyone for your great comments and participation and we'll see you again in November. Bye now.  ^M00:51:55