Hearing Issues for Students with Deafblindness #3 This video is posted online with the following chapter markers: Chapter 1. Review: Types of Hearing Loss - Conductive, sensorineural, mixed Chapter 2. Hearing Aids - Behind-the-ear, In-the-ear, In-the-canal, & Completely-in-canal, Bone anchored hearing aid Chapter 3. Cochlear Implant - Hearing aids and cochlear implants process & deliver sound differently Chapter 4. Structures of Cochlear Implant - The external and internal parts of a cochlear implant Chapter 5. Different Listening Needs - Medical devices can be programmed for different environments; i.e. classroom or travel outside. Chapter 6. Deafblind Difference - Children with deafblindness will have additional & unique needs for hearing. Chapter 7. Other Hearing AT - Other hearing assistive technology; i.e. FM systems, induction loop, sound field system, bluetooth devices Hearing Issues for Students with Deafblindness #3 Transcript [ Start slide: ] Chapter 1. Review: Types of Hearing Loss Adam: Thank you, Kate. I'm Adam Graves and I'm going to be facilitating this conversation today. And we're just going to start by reviewing the types of hearing loss. This is kind of a review from the first session that we had on hearing issues. And just a reminder of the structures of the ear because we're going to be talking about the -- how different devices work within the structures of the ear and in the process of hearing. So just as a review, a conductive hearing loss is one that affects the structures of the outer and middle ears, which are the physical structures all the way from your ear lobe to the tiny little bones at the end of your ear canal. And the eardrum. A sensorineural hearing loss is when there's damage to the inner ear, which is the cochlea, which is that little shell‑shaped bone that contains the hairs that vibrate and send a signal to your auditory nerve and it can -- a sensorineural hearing loss can also be caused by damage to the auditory nerve as well. And then a mixed hearing loss is when there is a combination of a conductive and a sensorineural hearing loss. [ End slide: ] [ Start slide: ] Adam: So those are the structures that we're going to be talking about. We've been kind of -- I think that it's kind of in our nature to compare hearing loss to vision loss, especially when we're talking about kids who are deafblind. And for those of us who are VI teachers, we always want to kind of make the comparison because we want to be able to know or have some similarities between what we know. And so I think that we have this slide that sort of makes a little bit of a comparison. Conductive hearing loss might be kind of the equivalent of a loss of visual acuity in that there is a potential there for correction for the hearing loss to be corrected to a near normal. But there isn't really much of a comparable -- there isn't anything in the vision world that is comparable to a sensorineural loss. There aren't any devices like CIs or hearing aids that can kind of make up for the neurological loss that you have in the case of like a CVI. And so that -- really that's kind of its own thing. And then the main thing that I think is really important to remember when we're talking about a hearing loss versus vision loss is that a vision loss doesn't really compromise the ability to learn language in the same way that a hearing loss will. [ End slide: ] [ Start slide: ] So that having been said, the type of device that a student is going to be using is going depend on the kind of loss that they have. And Lisa, if you want to give a little introduction about the difference between, say, a hearing aid and a cochlear implant and how they affect the way that sound reaches the brain. Lisa: Sure. Should I do that now or should I start with the hearing aids and then move on to cochlear implants? Adam: I think we're going to start with hearing aids and -- and the different types of hearing aids first. [ End slide: ] Chapter 2. Hearing Aids [ Start slide: ] Lisa: Okay. So on your slide you'll see some pictures of different types of hearing aids. Hearing aids, no matter what it looks like, what its built into, have three components. They're going to have a microphone -- it's going to have an amplifier and it will have a speaker. So the microphone is going to pick up the acoustic signal and change it to an electronic, an electric signal, and it's going to be then amplified and manipulated. There may be a small computer in there, processing how the sound is being amplified. And then it's going to be con--converted back to an acoustic state through the speaker and then sent down the ear canal. So a behind‑the‑ear aid, all of that is happening in the portion that's sitting back behind your pinna or the external part of your ear, and the sound is being sent down the tube through the little earmold. That's the part that fills up your ear canal, the plastic rubber piece that fills up your ear canal and it's sent down there. The second picture a little further to the right is another kind of version of a behind‑the‑ear. Some people call it a RIC or receiver in the canal. Same sort of thing is happening, just the parts are separated in different locations. So instead of it all happening in the part behind your ear, part of that is the receiver is actually in the ear canal itself. You'll also see on the bottom pictures of ears you will see a picture of an in‑the‑ear canal -- in-the-ear hearing aid, pardon me, where the whole hearing aid is in your concha or in the bowl of your ear and you will see or not see very well in‑the‑canal hearing aid and a completely in‑the‑canal hearing aid because all of those components are shrunk down so far that it's all inside a device that's either sitting in the canal or even a little bit deeper down in the canal. Chris: I'm sorry, I had a question, but I'll let you finish first. Lisa: No, go. Chris: Well, I was wondering, because I don't have much experience with students that I've worked with using in‑the‑ear hearing aids, is that more of an adult‑type hearing aid? Are they more fragile? Lisa: That's exactly what it is, we were on the same wavelength. I was going to say it's pretty rare to see an in‑the‑ear and in‑the‑canal or completely in‑the‑canal hearing aid on a kid for a couple of reasons. One is that, yes, they are itty bitty and they're fragile. The other issue is that as a child is growing, you end up having to recase the hearing aid all the time, so as opposed to if it's a behind‑the‑ear you get a new earmold which relatively speaking is inexpensive, but if you have to recase the whole hearing aid it's an expensive proposition. The other issue, too, is that, for a kid I can get an earmold that's pretty soft. So if they get hit, you know, out playing, it's not going to be as much of a concern as if it was a hard plastic device that could potentially break when it's hit. So there's that too. But I almost never see -- I hesitate because I have had a couple of high school kids have in‑the‑ear hearing aids, but that's been really,really rare. Kate: I'm sure that's harder to find plan a playground full of rocks. [ Laughter ]. Lisa: That's why I like the neon earmold, yeah, yeah. [ End slide: ] [ Start slide: ] Lisa: Oh, I jumped ahead, didn't I? Adam: That's fine. I mean, I think that we put this slide in here because this is the type of hearing aid that we're all familiar with. And the -- and the basic parts of the behind‑the‑ear hearing aid that is the microphone, amplifier and speaker are all contained in that little -- I don't know, what do you call that? Lisa: That's an actual hearing aid. So, yeah, I would say that's the hearing aid and then picture down below are the earmolds. Chris: And those are not neon. Lisa: They're not. They're cooler when they're neon. [ End slide: ] [ Start slide: ] Kate: Let me step in here before we go forward because we have a comment and a question. Angela says, all my student have behind‑the‑ear aids. I was wondering why some have molds and some have the receiver in‑the‑ear. I guess it's maybe their age, you talked about that. I was wondering if it had anything to do with the type of loss. Lisa: That's a good question. You know, the receiver in‑the‑canal, the RIC aid, are kind of the latest thing. So-- it's not necessarily degree of hearing loss. You will see some behind‑the‑ear hearing aids with -- I can't figure out where to look. I think a lot of the RICs that we're seeing now are just kids that have been fit more recently than some of the behind‑the‑ears. I have some concerns about the RIC because they seem to be more fragile than the behind‑the‑ears. So I am seeing kids getting fit with them, and depending on the kid it's been fine or it's been kind of an issue with things breaking easily. And I feel like there was a second part to your question. Let me see. [ Inaudible ] Kate: Does it relate to type of hearing loss? Lisa: I don't know that it is necessarily their age. I've seen little ones in RICs lately, too. I think it has more to do with how current the aids are and the philosophy of that particular audiologist. Chris: And Lisa, this information is probably old ath this point because it seems like hearing aid technology is moving really fast, but it seems I remember a day where, where the in‑the‑ear hearing aids didn't necessarily work as well as the behind‑the‑ear. Lisa: Yeah, you're right in that. As I -- as I was just talking, I was kind of comparing a certain size behind‑the‑ear with an earmold versus the RIC. But you're right in that I have kids with very profound hearing losses that have to be in a behind‑the‑ear and bigger version behind‑the‑ear, and there were certainly hearing losses that we could not reach with an in‑the‑ear. And definitely with a canal. The other thing that you compromise with some of those smaller devices, and even the behind‑the‑ear RICs, or -- or just the mini behind‑the‑ears, is the smaller they get the more features they end up having to drop off. So there's some aspects and we'll talk more about FM in a little bit, but some of those newer, really itty bitty hearing aids limit how -- what we can do in terms of that. [ Inaudible ] Chris: Those are for the vain adults in the crowd, right? [ Laughter ]. Adam: So would you mind talking a lot bit about the BAHAs? Because I think -- I didn't know what a BAHA was until a couple of years ago. Lisa: Yeah. Seems like you're seeing them a lot now. Adam: Yeah, more and more. Lisa: The types of hearing aids that we looked at before could potentially be fit on someone with either the sensorineural hearing loss that Chris was talking about -- pardon me, that Adam was talking about or a conductive hearing loss. You see those types of hearing aids on conductive hearing losses. BAHAs are generally for folks with conductive hearing losses or unilateral hearing losses, hearing loss on one side. And what a BAHA [ Inaudible ] does is it has a microphone and an amplifier, but rather than converting that information back to an acoustic signal, it -- it makes it a mechanical signal and it actually vibrates. You see this picture of the woman wearing the little blue BAHA back behind her head. So that little hearing aid actually vibrates. So if you hold that any place on your head, you will hear it because the sound, rather than tran -- going down the ear canal, is actually traveling through the bones in your head straight to the cochlea. Adam: It's like a tiny little boom box. [ Laughter ]. Kate: For a rock concert. [ Laughter ]. Lisa: So what that enables somebody to do is if you have a big conductive hearing loss or you have an ear canal that is completely closed or -- or you just don't have an external portion of your ear, if you put that someplace on your head, the sound will go to that cochlea. The cochlea is working okay. It's used with people with unilateral hearing loss sometimes. If it's an ear that we feel no matter how loud we make it on that side, it's just not going to sound good, somebody may choose to put a BAHA on that side so the microphone is over here and it's vibrating, but I'm actually hearing it on my good ear side. So ‑‑ Chris: Now that's crazy. Why is that? [ Laughter ]. Lisa: Yeah and the reason why we would do that is to help with hearing things that are on your poor side, right? So-- and strangely, I've heard that some people have learned how to localize, not sure how that happens, but -- but if a student is sitting in a classroom and a student next to them answers a question and they have just that one good ear, if they had the BAHA on, they would hear the sound on that side. And there's another hearing aid that will send it acoustically to the other side, too, but we may be going too far down a path that you don't want to go. But if they look like behind‑the‑ear hearing aids, but it's sending the sound from the side that we know we can make this loud over here, but it's just not going to get to that ear, we'll go ahead and send everything to the other side. Adam: Wow. Lisa: And BAHAs can be either surgically implanted. This woman has a surgically implanted BAHA. They actually put a plate back behind on that bone back here and there's actually it looks like a snap. It's kind of crazy looking. You just snap that right on to your skull, then there's a soft band BAHA, so you sometimes see kids with the little head band and the BAHA is on there. And they may do that if the family has chosen not to do surgery or the child is still young and they're waiting for their head to grow more before they do it. Chris: So Lisa, I think you -- I feel like you've already answered this question, but for a dense person like me, and maybe I need it spelled out, but why might a person wear a BAHA over a cochlear implant? Lisa: No, that's a good question. So BAHA is trying to address a hearing loss that is due to the sound not being able to make it through that little ear system to an intact cochlea. So if we can just get the sound signal there, those cochlea is going to work great. A cochlear implant is a device that is trying to help that sensorineural system work in a way that it is not working well. So, I think we have some pictures of that coming up and we can show how that happens. Some of them are made by the same companies and some of them, you know, had surgeries, you know, surgical scars that look somewhat similar, but they're trying to overcome two different things. Chris: So it's basically sensorineural versus conductive. Lisa: Usually, yeah. [ End slide: ] Chapter 3. Cochlear Implant [ Start slide: ] Adam: So the difference, I guess, what you're saying [ Laughter ]. Luckily we have a slide that really talks to this and addresses this -- this issue precisely. That hearing aids gather the sound and send it through a damaged system and then a cochlear implant will bypass a damaged cochlea; is that more or less... Lisa: Right. And so -- I know we have a slide of this coming up too, so basically they will do a surgery and they will implant electrodes, a little tail of electrodes that when the sound comes in to the microphone or the cochlear implant, it's processed in that computer and it sends rather than acoustically like the hearing aid or mechanically like the BAHA, it's going to be sent as an -- an electric signal. And that electrode is going to fire and since it's there inside that cochlea, when it's firing it's going to do what those hair cells weren't doing on their own and fire this strong synchronous kind of signal that then goes up the auditory nerve to the brain. Adam: So let's talk about the structures of the cochlear implant. [ End slide: ] Chapter 4. Structures of Cochlear Implant [ Start slide: ] Lisa: Yeah. Go ahead. Adam: So that's a picture of a young man with a cochlear implant. And those -- those are the external structures of the CI. Lisa: Right. So you can see... [ End slide: ] [ Start slide: ] Lisa: -- there we go. The part that the arrow is going to now is the processor, and so that is -- that is taking that information and the audiologist who is working with that student will set what's called a map, so we'll decide how to program what's happening to that signal. That is the coil, so it's the transmitter, so that signal is then sent to that coil. And this, unlike the implanted BAHA, is -- the implanted BAHA is actually snapped in to a little post that's coming through your skin, coming out of your skull. This is not. It's actually attached with a magnet. So you can actually place it. It's interesting. You kind of just have to hold it and then you find it. It makes its way to the magnet and it will stay there. [ End slide: ] [ Start slide: ] Lisa: And there's the magnet. So this is the part that is inside, underneath the skin. You see the magnet and the receiver. And then all those little arrows where it says electrode array, are all the different electrodes, and that is wound into that snail‑shaped cochlea. [ End slide: ] [ Start slide: ] Adam: So it's really, really tiny, but the electrodes are ‑‑ Lisa: Yeah, it's like a litte rubber Adam: Microscopic almost. Lisa: You can see the little bands, you can see it's small. I'm trying to think of something to equate it to. But you can hold it in your hand and it's just like a little skinny rubber piece that you can see the little stripes on. Adam: So this is a diagram showing how the-- it's just another photo or pictures explaining the components of the cochlear implant and how they fit in‑the‑ear, but I think we'll probably just go past this. [ Start video: ] Narrator: In normal hearing, the hair cells of the inner ear transmit information to the hearing nerve, which sends it to the brain. In most cases of deafness, the hearing nerve still remains functional, but the hair cells have been lost or damaged. In a cochlear implant system, sound enters a microphone and travels to an external mini computer called the sound processor. The sound is processed and converted into digital information. This digital information is sent over a transmitter antenna to the surgically implanted part of the system. The implant will turn the sound information into electrical signals that travel down to an electrode array inserted into the tiny inner ear or cochlea. The electrodes directly stimulate the auditory nerves sending sound information to the brain. Bypassing the damaged inner ear, the cochlear implant provides an entirely new mechanism for hearing. [ End video: ] Adam: So that's how a cochlear implant works. And -- and all of these things, the hearing aids, the cochlear implants, the BAHAs, they can all be programmed, right, for different hearing environments, is that correct? Chapter 5. Different Listening Needs [ Start slide: ] Lisa: That is correct. So, the hearing -- hearing aids, yes, the BAHA, the hearing aids, most hearing aids anyway, and the cochlear implant, can be programmed not just to that person's particular hearing loss, but also for different listening situations or multiple programs if the audiologist and the family or the patient feels like they're capable of manipulating different programs. There might be multiple programs in those devices, so that person would switch when they enter a certain situation and it will change, the kinds of sounds, how the sounds are being manipulated. So yeah, they absolutely can. Adam: Wow. So like -- So if you're in a loud room, say there might be a certain setting on the hearing aid that they could switch to kind of filter out some of that noise? Lisa: Yeah. That's the most common, kind of most multiple setting would be a setting for if it's a noisy situation where they will try to cut out some -- a lot of noises, low frequency information, so it will try to cut out some of that. There might be a program for music where you might not want to cut out all that low frequency information, it doesn't sound good when you do that. So there's a whole bunch of different situations. There's really it seems unlimited number of ways that you can manipulate what's going on. Adam: So how, how do you know -- how would a parent or a teacher know how to -- what -- what would be best for a student and what program would be best for them? Chris: Especially if they don't have a lot of language. Lisa: Yeah. The audiologist who is doing that fitting, there are complicated and different fitting philosophies that are proposed. Frequently -- There's one for example called DSL, desired sensation level. It's a hearing aid programming strategy that was designed specifically for kids because we realized that the kind of information we want to give kids is different than somebody who already has language, let's say. And has that -- already has the knowledge of speech. And so that fitting strategy is one that's pretty widely accepted for kids, and so usually we would start with that. And a lot of times when it's a small kid, at least my preference, is that there not be multiple programs. Because, you know, kids are playing with their hearing aids and I don't necessarily know if they've now switched themselves into a program that's cutting out sounds that normally I would want them to hear. So I usually start off with one program, so the folks who are working with that student in school wouldn't need to make decisions about the programming, but what would be really helpful is if they provided information to the person who is programming about what this kid's day looks like, situations where they're seen if they're having more difficult, what's happening with speech and language. That's a good flag of maybe we're not giving them enough of this because they're not producing this particular sound. Maybe there's something else that I can do. Maybe they're not hearing that sound. So all of that information is important as the fitting process goes on. It's a multi step thing. It's not like, oh, set, go forth now. Things are going to be changed as we get to know the family and see how the kid is doing and we get information from the school. Kate: So Lisa, let me ask you this -- this is Kate. Long ago and far away when I was in a class with deaf children, deaf preschool children in particular, we got them FM systems the minute they walked into the classroom. [ End slide: ] [ Start slide: ] Kate: And kept it pretty much all day on, you know, the teacher's voice and this, that and the other because we were wanting to ensure that they got as much auditory input together with sign language and whatever as we could and that they were paying attention to the adult voice. I don't see that FM systems in classrooms very much anymore. And what I'm wondering is the reason being is that are... you know, when the kids that I had, they basically had one setting. Half the times the hearing aids didn't work, that sort of stuff. I'm wondering if it's because, you know, we were not seeing as many FM systems is because we're better to program more efficiently or more effectively with the hearing aids nowadays? Lisa: I wish I could say yes, but I can't say yes. Because FM's are still the best way for kids to hear the teacher's voice or a speaker's voice from a distance or in background noise. As great as these hearing aids have gotten, the example I always think of is okay, we've taught a hearing aid, we want you to amplify speech. Speech is really important, but we haven't taught a hearing aid to figure out which person's speech is the most important. So if -- it's going to take the one that's closest to you as the one that should be amplified the loudest. And so if that loudest voice is the kid sitting next to you, then that is going to be what you hear. So -- so what the FM does, just like you described, is it takes that teacher's voice and it sends it directly to the hearing aid. They're still going to, if we've got it set up the way that I think it should be set up, and I think the way most people do, those microphones on the hearing aids are still on because we do want that student to hear the kid next to him and we want that student to hear their own voice, but we want the primary signal when the teacher is instructing to be that teacher no matter how far away they move. I would love to think, although I may be fooling myself, that maybe the reason why you're not seeing FM's as much, is that they've gotten so much smaller. Like when I first started working in the field, you knew when a kid had an FM on because it was strapped to them. Kate: Yeah, they were huge. Of course all of our kids were in body aids at that point. Lisa: There was no question. There was an FM on. There's a big harness and the wires going up to their ears. But -- but now the FM's are itty bitty things that are just hooking on to the bottom of the hearing aid. Kate: Oh good, maybe that's what it is. And here's a comment that maybe confirms that. Angela says, I get all of my kids FM systems. They are a must for classroom instruction. However, the FM systems are on all my hearing aid kids. What about CIs? Is it possible to put one on a CI and are they needed as much for CI wearing students? Great question. Lisa: And the answer is yes and yes. [ Laughter ] Chris: That's two answers [ Inaudible ] . [ Laughter ]. Lisa: Yeah. Most -- I'm going to say all CIs are compatible -- all CIs that I know about are compatible with an FM in one way or the other. There -- there are different ways and I think we're going to get to that in a little bit, on how you can hook an FM to different cochlear implants. And it is absolutely just as important because the CI suffers from the same issue as the hearing aids do with background noise and distance from the speaker. So absolutely. Good question. [ End slide: ] [ Start slide: ] Chapter 6. Deafblind Difference Adam: And I accidentally skipped ahead, but I think that's probably a good point for us to -- to move on to talk about how programming a CI or a hearing aid for a student who is deafblind would be different for a student who can see. And I think we've talked a lot about the need for students who are deafblind to be able to hear environmental sounds. And for kids who have vision, those are the types of things that we want to filter out, but, for example, if you have a student who is using sound cues in order to find their classroom, like say a soda machine or the sound of the music room, you don't want that blocked out -- you don't want that filtered. So can you talk a little bit about that and how we might be able to, like, reprogram things or how -- when is a good time to provide that information? Lisa: You know, I would think as soon as you're involved. This is a big ah‑ha moment for me coming here and -- and talking with you and thinking about this because I'd like to tell you that in the past I thought about all of that as I was fitting cochlear implants or hearing aids, but I honestly wasn't. I was focused on ears. These are -- This is my device, these are the ears. I wasn't thinking about all the rest of that person and what different things they might need to hear specifically in someone with a visual impairment. So I think that the sooner you can get involved and talking with that programming audiologist or the audiologist fitting the hearing aids the better, I realize when I have this realization I went oh my gosh, I've really not thought about this. I want to talk to other people and see what they're doing. And I started asking people and the responses I was getting even from audiologists that work for hearing aid companies were things like, oh, yeah, that's good, it's like -- but people hadn't really thought about it before. And they were excited to think about how they could be doing things differently but it wasn't I think until people pointed out to me anyway like listen, "these sounds that you always thought of as noise are trash. We don't want to hear them. They're getting in the way of speech and language." Are actually -- can be very important. And we have the lovely ability now to not have to choose to do -- have a program one way. And now that I've said I'm going to take it back that I would only have one program on a kid, on a kid with a visual impairment, I may break that rule because it may be that in certain situations where we're really working with environmental sounds, I would have one program and then when the goal is for them to hear as much speech and language as possible, I might have another. Adam: Like, for example, you might have one program for when they're traveling in the hall and then a different program for when they're in the classroom and they need to have those filters because they need to be focused on speech. Lisa: And there needs to be good communication between myself and the family and the school because that child may need -- will likely need help making sure they're in the right program. When I have a high schooler I can say okay, hit the button and you will hear two beeps and your program two, but for a student we all have to be on board and there is no just rule like I know program 2 is this. It's not. It's however that audiologist has decided to set the program up and what's going to be the default and what's going to be program 2. And that might be different for ‑‑ Adam: It's not like factory settings. Lisa: No, no. So -- Actually, just yesterday I had a conversation with another audiologist who is going to fit a hearing aid actually on a student who has deafblindness. And we were talking about what should the default program be, knowing that when they hook the FM on it's going to do one thing. Do we want it to default to this? If the battery door opens and closes again it will default to this one program. What do we want that program to be? Do we want it to be the one that they're using out here or the one that -- and it's going to be different for each kid. Like in this situation it's like, you know, the parent -- we'll make the default for the school because I'm not sure that the school is going to remember to set it to the second program. And I know this mom will. Or it may be the other way around, that you want it to be the easiest thing at home and they just close it and go and school changes it. So just -- it's very individual. And that's why the more information that the audiologist has from what the student's day looks like, the more helpful, and then maybe it changes. Maybe next year school looks different and we need to totally change how this is working. Or we're finding that the one that's the environmental program, they hate listening to it because they say it's too loud. Maybe we need to change some of those settings and figure it out. It's just kind of an on going thing. [ End slide: ] [ Start slide: ] Adam: We talk a lot too about being able to help kids who are deafblind learn how to localize because that's one thing that a -- that a student who has vision and hearing loss, that's one of the things that they learn to do using their hearing aids, but it's much, much harder if you can't see where a sound source is coming from. And so -- Lisa: It is. And as I started reading more about that too, I realized that it's actually much harder for someone in hearing aids than it is for someone without hearing aids, for a variety of reasons, including how the hearing aid may be processing sound, but also the location of the microphone of the hearing aid kind of messes with the local localization. And there are some companies that are trying to account for that and say people are looking better with this because we take into account. So there's all of that information and we've talked before about like directional microphones, which are sometimes used to try to help speech and noise with the assumption that it was behind me it's noise and I don't want to hear it, so the microphone may go just in front of me, but that's a big problem if you're trying to cross the street and there's a car coming behind you. But this is stuff that I never really thought about, and it wasn't until I got the opportunity to talk with you and to go and see someone doing an O and M listen where I was like, oh, okay. And so I think there might be audiologists that have thought a lot more about this than I did, but I think there's also ones that, we're so specialized, so specific in our areas of knowledge that you don't always know about and think about these other aspects that would make us better at fitting hearing aids, but don't even know to think about those things. We're so thinking about the auditory stuff. [ Inaudible ] Adam: Right. It sounds like it's something that everybody who is working with a child who has a dual sensory impairment really needs to be aware of, especially if they've got some sort of hearing aid or cochlear implant or whatever. Lisa: Definitely. Chris: And Lisa, I wonder, all that in mind, if there are any hints, suggestions that you might give for the teacher or parent who is helping map a cochlear implant or get hearing aids adjusted correctly and they talk to their audiologist? Kate: While we're kind of getting Lisa back up, one of the things that will be -- be a possible strategy for teachers out there, especially in thinking about teachers of the deaf and hard of hearing who might be joining us is if you're working with an audiologist who hasn't worked with kids who are deafblind and hasn't thought of that, this webinar will be archived on the TSBVI website and may be turning them on to a little piece of that information might be a way to kind of give them an ah‑ha and be able to sort of advance their knowledge of trying to fit for a child who has no vision or little vision. [ Inaudible ] Lisa: My answer to that would be to have the family and/or the -- the teacher communicate with the audiologist about what the student's day looks like and what their goals are and ask, just ask -- because I don't have all the answers on exactly how it needs to be done so I can't say tell them to do whatever. I would say hey, listen, you know, we're working on orientation and mobility. And this is what that looks like. We go out and just ask, what do you think the hearing aid is doing when a car comes from behind? And then -- Or I'm watching this kid and they seem to have trouble in this situation. Is there something like -- just ask questions. Chris: Real world hearing, like what is happening and how do we ‑‑ Lisa: Exactly. That's not information that we frequently have or I did when I was in a clinical setting inside a test booth with a computer that is telling me the targets that I want my hearing aids to hit. And when I get all my targets, I go oh, I did a good job. It's been fit. But -- but it's a very specific situation and so if it's an adult they might come in and tell me, I was here and this happened. Why is that? But with a kid I don't have that, so the more information I think that you can bring. And -- and to tell the family that they have really important information to share with the audiologist. Yes, the audiologist has specialized knowledge and they know how to fit that hearing aid, but the information that they can share will help make that a better fitting. So if they don't share that, I think it's a missed opportunity. Or they don't realize that that's important information and the audiologist doesn't think to ask, then there's an opportunity there to do a much better fitting and help the kid more that we're missing. Chris: Okay. Robbie has a question too that she would like to ask. Robbie: Last year we had the opportunity to work with Lisa and come up with a list of best practice things to do when you have a student with deafblindness and you're consulting with an audiologist. There was a TETN done and Kate, is that up for people to view? Kate: I believe it is, but I will double‑check here in a second and post the link to it on the web, okay? Robbie: Yes. I think that the one thing Lisa cautioned us is to not expect the family to convey information from the professionals because if the family goes in and says I want noise, background noise, and my -- and my -- to have my child to be able to access that through their assistive listening device. And the audiologist might say "What? Noise!!?? We don't do noise!" So what we recommended is that an audiologist writes a -- a report or recommendations on the functional impact of the hearing loss across settings aided and unaided. So having a consultation between the audiologist and the teacher of the visually impaired and the teacher of the hearing impaired is really important. and if you -- Kate is going to put up the link. We do have a process that was worked out and recommendations, and this year we're going to be working on coming up with materials to assist with this consultation that Lisa will be helping us with. That's it. Thanks. Adam: Thanks, Robbie. Chris: Thanks, Robbie. [ End slide: ] Chapter 7. Other Hearing AT [ Start slide: ] Adam: Alright, We only have five minutes left and I really want to talk about hearing assistive technologies, especially FM systems, because we've been referring to them quite a bit and there might be some people out there who don't know what an FM system is. [ End slide: ] [ Start slide: ] So -- if we can move on then to an FM. And basically, Lisa, I'm going to try and describe it and you can correct me if I'm wrong. [ Laughter ]. An FM system consists of a microphone, which is worn by the speaker, usually the teacher in the front of the classroom. And then that teacher has a transmitter which is actually now much smaller than that box which is pictured. And it transmits either directly to an attachment that goes on the back of the hearing aid or to a receiver that is worn by the listener. And it goes -- so it's a personal listening device, a personal signal that goes between the teacher and the person who is listening to that person. Is that accurate? Lisa: That's right. So that picture of that FM system, actually, the only thing that I would jump in is that the newer FM systems, actually the transmitter is not a whole lot smaller. It might even be bigger than that one. [ End slide: ] [ Start slide: ] But the receiver, the little silver tube that you see on the bottom of that picture, or on this one, the little kind of transparent thing that's hooked into the body of that blue hearing aid, they're getting smaller all the time. That teacher transmitter is -- you know. Chris: And it's an FM system so it's radio waves. Lisa: That's right. So there's a transmitter and a receiver just like a radio station. Chris: CB radio. Lisa: A radio in your car. And actually there's technology now that is not technically FM, but is doing the same thing. So I haven't really made the flip of calling it something else because I can't figure out what to call it so people know what I'm talking about, but it's the same idea. There's a transmitter and a receiver. And as you mentioned, the receiver can hook to the bottom of a kid's hearing aid or cochlear implant. It can be a receiver in a loop that's worn around your neck. That's using -- that's going -- that's sending the signal to the hearing aid or the cochlear implant either through bluetooth or through a telephone coil in the hearing aid. Or a speaker. It could just be going to a big loud speaker that's in the room. Adam: Right. And the telecoil is the -- is on the next slide. [ End slide: ] [ Start slide: ] Adam: Like the hearing aid has a setting that -- is it -- is it a setting? Lisa: It is. It used to be just a little switch. Now it's a program. So you would go ,for this right here, either for this big room, induction loop, or in the one that you wear around your neck that works off of what we call a telecoil or a telephone call because it's designs that you pick the phone up and it picks up the phone. So the signal is being sent to the hearing aid through that. And that can be hard wired in a room, although you don't see that in classrooms very much because it's not very portable. If the kid moves up to the next classroom and it's installed in your wall, but you will see that out in public. Adam: Church is where I always see it. A lot of churches have an induction loop. Lisa: Yes. Then someone who comes in with a hearing aid just flips to their telephone program and they can hear the person using the microphone. So you don't need to have anything to hook on to a whole variety of hearing aids that might walk into that room, as long as they have that telecoil. And most of them do nowadays, right? Lisa: They do. As things get smaller and we're kind of moving a little bit away from the telecoil and more towards some of the bluetooth streaming stuff. [ End slide: ] [ Start slide: ] Lisa: And I think the next one -- there's a neck loop, so that's working the same way as that big induction loop in the classroom. The teacher still wears a microphone and the student is wearing that around their neck, signal is going from the teacher to that little box and then traveling from that little box up to the hearing aids. [ End slide: ] [ Start slide: ] Lisa: And then here's a picture of the sound field system so you can see in that little picture that the teacher has a microphone, a transmitter on. And behind her that little pole back there is actually a speaker. So the sound is going to the receiver in that speaker and then being amplified throughout the classroom. [ End slide: ] [ Start slide: ] Lisa: And then you can also use bluetooth, and this is the way this is working now in the classroom well -- is if the teacher uses the transmitter that goes to a streamer, a bluetooth streamer, which is then sending the sound up to the hearing aid. I have a couple of hearing aids that have bluetooth built in, but it has not in my mind been a good match for the classroom yet. It's really designed more to use with your telephone or your iPod. So it does -- doesn't have the battery like you need for a full class day. It doesn't have the distance that you have with FM. So there's problems -- we're starting to see it pop up more. I think we'll get there maybe, but I -- but I've had audiologists say oh, you don't need FM because you can use bluetooth, but it's not quite there yet. Adam: It's not as reliable it sounds like. Lisa: It isn't. And then there's, you know, there's just different, yeah, problems. If you can't get quite as far and the student has to be in a certain location or There's -- the microphones sometimes with these bluetooths are not as good. They're small, but they're not as good as the ones you would use in a classroom. They would be great for at home or you're in the car and the person is in the back seat and the driver has a little microphone that goes to the bluetooth. Yeah, but for a classroom really these other systems are better. [ End slide: ] [ Start slide: ] Chris: I had a coworker show me her new hearing aid recently and it kind of blew my mind. It was a very small behind-the-ear hearing aid, and I was amazed about everything she could do via bluetooth with this. She was -- she had a little device that she could hook into her television. I was just wondering if you could expand on my little bit of knowledge of that, like other ways a person hook-in to technology with their hearing aids. Lisa: I got an e-mail today, about a student with a cochlear implant, and they are doing a bunch of STAR test practice on the computer, and they are trying to figure out how to hook her up to the computer, and using the bluetooth streamer is one of the ways we could do that with her. The bluetooth streamer can be paired that with all sorts of stuff right, it can be paired with your phone, your iPod, your car radio, whatever, so that signal would go directly to that streamer, which then talks to the hearing aid. Like I said, I have seen a couple of hearing aids where there isn't that third piece and it's going right to the hearing aid. Yeah, [ Inaudible ] that's where I think we're heading. Chris: That's what my coworker's does, I was amazed, it was very small. Lisa: Yeah. Adam: It's sound like the bluetooth is used more for personal devices, where as the FM is better for a large setting, where there is going to be multiple people -- Lisa: It is right now, definitely. I can see it going that way,that's where, you know, we'll end up, and wouldn't that be great when the kid shows up and they don't have to hook anything on to their hearing aids, we just have the teacher transmit her part in. Kate: And for someone who is deafblind, and doing computer work, and they have JAWS going, then they could navigate the computer via bluetooth auditorially to get to where they needed to go, so it would give them access to the internet in a way that they haven't really had before. Lisa: It's been interesting, when some of the companies were first coming out with the bluetooth stuff, one of the gentleman who came to talk to me from one of the manufacturers said that all of his coworkers could -- I guess get them inexpensively since they worked for the company, were getting hearing aids even though they didn't have a hearing loss, so they could use them with all this cool stuff that you could hook it up to. [ Multiple Voices ] [ Inaudible ] So yeah, it's very cool, with the phone, so you get a phone call, you know, hit the streamer, it picks it up, and your hearing it right in you hearing aid. I really appreciate your comment Kate about JAWS and the voice output devices that we use with children with visual impairments, and I think one thing we need to do when we do evaluations, tech evals, is to test the deafblind child's to understand this type of speech, because a lot of times they understand speech based on intonations, and so computer speech is a different challenge, when you have a hearing different -- so that would be a very important piece of a tech eval, when you are looking at devices typically used for visually impaired students with normal hearing. Kate: Yeah, looking to see, you know -- with JAWS you've got preferences in voices too, so that might be that one voice they would be able to hear better than another voice, based on the hearing aid setting or whatever. Adam: Well and also based on the type of hearing loss they have, the low frequency loss, high frequency. Kate: It probably wouldn't be for every deafblind student, but there would be some that could perhaps make use of that. Okay, I think that's it. Adam: Thank you everybody, thank you Lisa. Good to have you here. [ End slide: ]