The seasons are changing and with that change comes increased congestion for children around the world. Whether you are moving from fall into winter or winter into spring, the changing temperatures, moisture levels, and changes in the trees and other plants outside can produce allergic responses in children and adults. So while these changing seasons can often bring increased opportunities to get outside with all of those benefits to breathing, regulating the nervous system and disrupting repetitive behaviors, there is the real issue of increased congestion.

So what’s the big deal with congestion? My grandchild’s pediatrician told us that we should expect my grandchild to be sick 90% of the time if she attended a preschool or day care. The doctor went on to say that this was nothing to be concerned about because most of the illnesses were just colds and congestion. What that really meant is that my grandchild would be experiencing distorted auditory information 90% of the time. That’s a big deal.

Whether children attend preschool, playgroups, grade school or go to “kid gyms” the increased exposure to illness combined with seasonal allergy triggers create a perfect setting for long periods of congestion. If congestion is so common among children in the general population, why are we so worried about it? Why should you be concerned? The short answer to that is that it impacts negatively on the quality of sound that is being transmitted to the brain.

Let’s look at how this might impact on a child with Down syndrome or any other syndrome that impacts negatively on the structure of the sinuses and ear canals. With many children, the ear canals tend to be small. By the way, many neurotypical children have small ear canals as well. These narrow canals make it hard for physicians to see or address typical issues such as ear wax that reduces the ear drum’s ability to move as well as making it difficult to see ear infections. Nasal and sinus congestion backs up into the middle ear causing the eardrum to lose much of its movement which then results in poor communication of accurate sound signals. Your child is not hearing with clarity. What they hear can be muffled and difficult to understand.

Obviously receiving poor quality sound impacts negatively on auditory processing, auditory attention and the development speech and good articulation. It also results in the child not necessarily responding when spoken to, being slow to imitate sounds, and appearing to tune out to what is going on around them. There’s more bad news in that nasal congestion produces mouth breathing which results in the child leaving their mouth open for long periods of time. This allows the jaw to stay in a relaxed position and can lead to the tongue sliding forward. So we have a cascading impact triggered by congestion.

Now let’s consider the impact on children with sensory issues. Have you ever had a cold and had that feeling of being detached from what is going on around you? Your head hurts. You’re tired because the congestion disrupts your sleep and you feel spacey because your hearing is distorted and even your sense of balance is impacted. You can’t taste your food and don’t even feel like eating. If this is how you feel with a cold, imagine the impact of congestion on your child with sensory issues.

For children who already may spend a great deal of time not processing auditory input or not processing it accurately, congestion adds another layer of distortion and isolation. We spend a lot of time doing program pieces that require and invite children to attend well to auditory input, to language, frequent congestion can result in even less attention to auditory input and a resulting increase in DSA’s (stimming behaviors).

So what can we do about this? Our best bet is typically to improve or maintain an extremely healthy diet rich in deeply-colored and diverse organic vegetables and healthy proteins. We will talk about nutrition and diets as a regular part of our monthly newsletters in the future. For now, let’s just simply state that we want to avoid mucous-causing foods during any period when the weather or exposure to other people may increase the risk of congestion. Typical mucous-causing foods include dairy, eggs, pasta, cereals, bananas, potatoes, corn, soy products and to a lesser degree, cabbage, corn and red meat. Many of these foods are not good for a variety of other reasons as well.

In future articles we will write about how to get your child to eat “the good stuff” and we encourage and invite you to share recipes and ideas on our Facebook page. Let’s help each other discover great ways to get our children to eat well. I’ll give a little shout out here to one of our new families in Australia who grow all their own organic foods for themselves and their little girl. Evie is a very lucky girl to have such incredible food resources. Unfortunately, we don’t all have a home that would easily allow us to grow all of our own food but we can share resources from around the world to give our children and ourselves the best nutrition and health possible.

Reprinted by permission of The NACD Foundation, Volume 33 No. 11, 2020 ©NACD

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It appears that middle ear fluid (otitis media with effusion) is a significant problem for children with Down syndrome. Our experience at NACD with literally thousands of children with Down syndrome indicates that middle ear fluid issues are ubiquitous and are of tremendous concern relative to the global development in this population.

For forty years NACD at any given time is working with approximately 300 children and adults with Down syndrome from all over the world. We work with the “whole” individual and look for correlations between issues to determine how to best address problems and global development.

One of the ongoing issues affecting overall medical care and therapeutic intervention, particularly as is it impacts children with developmental issues and complex interdependent issues, is the compartmentalization of the care. At NACD we are acuity aware of the importance of working with the “whole” child. Looking at isolated pieces can lead to ongoing issues that can have very significant impact on the child’s development and could possibly be remediated if the need were perceived based on the totality of the impact.

When looking at the “whole” child, it is possible to identify discrepancies in development. Development in children with Down syndrome typically follows “normal” development. This development, albeit slower than normal, follows the same patterns and exhibits the same associated developmental pieces as ‘typical” children. In areas where there are inconsistencies in the development of associated pieces, it is necessary to identify underlying cause. Often when language is delayed more than other areas, the underlying cause is something that is adversely affecting the hearing.

When dealing with a problem such as middle ear fluid, we want to address cause when possible. Mucus and congestion are virtually synonymous with middle ear fluid. It would appear that we could avoid at least part of the fluid problem by more aggressively addressing the cause of mucus. Many children have allergies that can be treated, but mucus-producing foods are in most every child’s diet. It would appear that if we could eliminate dairy and gluten from our children’s diets, we would probably go a long way toward avoiding or mitigating these issues.

Children with DS have anatomical issues that increase the prevalence of middle ear fluid. These issues include large adenoids, small nasopharynx, impaired swallowing, and narrow and abnormally horizontal Eustachian tubes. These anatomical issues, coupled with the fact that children with DS tend to have excessive mucus and excessive earwax, further complicates the problem. Middle ear fluid issues often resolve themselves in typical children; but the anatomical issues associated with DS make this substantially more difficult.

One of the issues that appears to create problems for children with DS is that middle ear fluid, even if considered in the “normal” range based on tympanic testing, can still have a significant impact on the hearing and development of this population. Over the course of decades, we have seen numerous cases where at parents’ insistence tubes were inserted even though tympanograms indicated that fluid was still within “normal” ranges.¹ Following many of these procedures the doctors commented after the procedure that there was much more fluid than expected. It appears that for the majority of children with DS having received tubes, even when the need based on the exams and testing was questionable, there were virtually immediate positive changes in language development. I leave it to the ENTs (otolaryngologists) to research and determine if different testing, norms, or criteria are needed. This is clearly an area requiring further investigation.

Complicating the issue as to whether or not to place tubes is the issue of what level of baseline testing is needed. Often children will have a flat tympanograms, and the doctor’s recommendation is to wait two, four, or even six months to repeat the testing. For a child, particularly a child with delayed language and cognitive development, two months or more can have tremendous impact on the child’s future development. If the doctor wishes to be cautious, repeat the tympanogram in two weeks. One might also consider the child with chronic congestion who will have some degree of associated chronic middle ear fluid. Why not in such cases insert tubes to assist with the mechanics and help drain the fluid? When this issue is seen relative to its global impact on the development of the child with DS, I believe aggressive treatment can be justified. Tubes would appear to be a relatively simple, inexpensive, benign treatment that can have significant, if not dramatic, impact on a child’s development and future.

To understand the significance of this issue, let’s look at developmental issues that can result from perhaps even a moderate issue with middle ear fluid.

Middle ear fluid issues have a negative developmental impact on numerous foundational developmental issues including:

• Hearing

• Receptive language development

• Expressive language development

• Speech/articulation

• Auditory sequential processing, short term memory, working memory, and cognitive development

• Attention

• Reading

• Balance, mobility, walking

• Visual tracking, convergence, strabismus

Hearing

Hearing involves sound waves moving into and through the outer ear and impacting the eardrum. The sound waves vibrate the eardrum, which in turn produces movement of the three small bones of the middle ear. The middle ear is a cavity containing air that should have the same atmospheric pressure as that outside the body. The pressure is regulated by the Eustachian tubes, which go from the middle ear to the upper part of the throat. The sound waves then produce vibrations on the oval window that then transmits the vibrations to the fluid in the inner ear, which in turn stimulates the hair cells of the cochlea, transforming the vibrations into nerve impulses that enter the acoustic nerve and then the brain. It is the brain that actually interprets the information and “hears” the sounds or words.

One of the immediate issues with middle ear fluid is resulting hearing loss. Numerous studies have equated hearing loss in DS to middle ear fluid. ^2,3 Conductive hearing loss, which is common in DS, is usually caused by middle ear fluid, but can also be caused by excessive wax.

Receptive Language Development

Receptive language refers to the ability to understand language. Every child begins learning to understand language by hearing specific words in association with specific objects or events with sufficient frequency, intensity, and duration. The consistency of this input is imperative for the child to literally learn to hear and understand. A completely deaf child receives none of this auditory input; a child with a hearing loss receives poor input; and a child with inconsistent input resulting from variations in middle ear fluid receives often less than the necessary quality of input needed for receptive language development. Receptive language is the first step in the development of expressive language, speech, and cognition.

Expressive Language Development

Expressive language/talking has been historically one of the biggest concerns for children with DS. Sometimes those not understanding the foundational issues will out of vexation resort to sign language or augmentative communication to facilitate communication and avoid frustration. Lack of function should not be perceived as a lack of potential or inherent ability to develop that function. If a child with DS is not talking, there is a reason that needs to be identified and addressed. Rarely do children with DS have oral motor issues or apraxia to such a degree that it prohibits the development of basic language, even though such issues can affect the speech. Significant delay in the development of language in a child with DS is virtually always a reflection of an issue with hearing or inconsistent hearing.

Speech/Articulation

Developmentally we refer to speech/articulation as the production and clarity of speech. A significant component of speech is oral motor function, which is a very common issue with children with DS. However, you cannot reproduce what you cannot hear. Middle ear fluid issues can produce issues with learning to process specific frequencies of sound. If you cannot hear, or if your brain does not learn to hear, a specific frequency, then it can’t be reproduced. Case in point, there is not an “r” sound in Japanese, and even for a native Japanese speaker who becomes fluent in English, the “r” sound may be next to impossible to learn because when their brains were learning to hear, the opportunity to hear that sound did not exist. Repeating the word “rice” typically comes out as “lice,” regardless of the number of times they hear the word spoken correctly. Audiograms, which only measure typically six frequencies, do not identity very specific frequency issues. We have used voice analysis to gain a better understanding of specific frequency issues and have discovered that they are extremely common. I would like to see research directed at seeing whether voice analysis could be used to accurately assess hearing more specifically and objectively than an audiogram or in conjunction with and audiogram.

Auditory Sequential Processing, Short Term Memory, Working Memory, and Cognition

Language and the development of language is primarily a reflection of the development of auditory sequential processing. Expressive language will not exceed the ability to sequentially process, hold, and mentally manipulate auditory information. Auditory sequential processing/short term memory is measured in pieces of auditory information that can be processed in a sequence or chain. This is often tested and measured by how many numbers you can hear presented in a sequence at one-second intervals. It could also be measure by the ability to listen to and repeat random words also heard at one-second intervals and repeated or how many simple directions one can hear in a sequence and then carry out. Generally, a child who can follow one simple direction will use random isolated words, working into functional use of individual words. As the child moves into being able to follow two-step directions, they will begin using two and then three-word phrases. When they can sequence three pieces, they will start using four, then five words in a sentence. As their auditory sequential processing increases, so does their receptive and expressive language.

The foundation of working memory, which is now appropriately being called the new IQ, is built upon the short-term memory. Working memory essentially represents complexity of thought and is reflected in global maturity and executive function. All of this put together represents cognition, which is simply that which permits us to learn, think, and communicate.

Issues affecting hearing in the first few years can have a negative impact on the development of all of these critical pieces, an impact that may not be able to be entirely remediated, or which requires years of extensive specific targeted intervention.

Attention

Over six million children have been diagnosed with the mysterious “disease” of ADHD, which is termed as a mental disorder, rather than a developmental disorder. Perhaps this delineation is based on a perception that a mental disorder can be treated with drugs, as opposed to a developmental issue that cannot. I believe that one of the most common issues affecting attention is auditory sequential processing and that one of the primary causes of auditory processing issues is recurrent middle ear fluid in children. The inconsistencies in hearing adversely affect the child’s ability to attend to and process language, resulting in slow or underdeveloped auditory development, including auditory sequential processing. Negatively impact auditory processing and you subsequently negatively impact auditory short-term memory, auditory working memory, executive function, and global maturity. The term ADHD is at times used as a secondary or dual diagnosis for those with Down syndrome and other developmental problems, but the symptoms that result in this label exist in every child with a developmental cognitive delay. It is questionable at the very least to ignore the cause or causes and needed developmental intervention by attempting to mask the symptoms with medication.

Reading

Learning to read can be very negatively impacted by even minor hearing or specific auditory tonal processing issues. Teaching reading using an auditory tonal and auditory sequential processing approach, such as phonics, is often disastrous for those with Down syndrome because of their auditory issues. However, children taught reading through a more visually based sight word approach do much better. A visually weighted word attack approach still has a significant auditory component. Issues with auditory tonal and sequential processing have a negative impact regardless of the reading approach, but significantly less of an effect with a sight-reading foundation.

An additional issue relating middle ear fluid and reading is the role of the vestibular-ocular reflex in reading and writing. The vestibular-ocular reflex is a reflex that associates activation of the vestibular system and eye movements. Any interference in this reflex adversely affects the ability to maintain focus. There is almost constant slight head movement when one is reading or writing. Interference in the vestibular-ocular reflex negatively impacts the compensatory eye movements that permit the child to sustain focus.⁴

Balance, Mobility and Walking

Walking has a profound effect on neurological development and is associated with language and cognitive development. Children with DS often have issues with tactility, muscle tone and strength that can delay and or complicate gross motor development and walking. These issues are only compounded if the development of balance is compromised. Middle ear fluid has a negative impact on the inner ear’s balance/vestibular system, as well as the vestibular–ocular reflex, further complicating the development of balance, depth perception and thus walking.⁵

Visual Tracking, Convergence, and Strabismus

The vestibular system plays a significant role in the development of ocular control, tracking, and the development and severity of strabismus. The vestibular system as mentioned previously affects the movement and control of the extraocular muscles that are responsible for visual tracking and which need to work in concert to keep the two eyes working together.

It is not unusual to see children with DS suddenly develop a strabismus or to see it suddenly get worse.⁶ When we become aware of these issues, we suggest that the family visit their ENT first, not their optometrist or ophthalmologist, because the most likely cause of the issue is middle ear fluid. Strabismus, which is a misalignment of the eyes, can take many forms, but generally the family will observe one eye or the other going in toward the nose or out toward the ear. If a strabismus exists the child is unable to perfectly align the eyes together, with a resulting loss of depth perception. It would appear that even slight issues with middle ear fluid could have a negative impact on ocular control and a negative impact on a wide range of functions. 

Conclusion

Seen in isolation some degree of middle ear fluid may not appear to be of great significance. However, in viewing the global aspects of middle ear fluid we have an issue that can have wide ranging and significant impact on a child’s future development.

We urge parents and professional to be vigilant and to address ear fluid aggressively. Remediation of issues associated with middle ear fluid generally requires targeted, vigorous, dynamic, and coordinated intervention.

References

1. Ear Center: Ear Tubes (Bilateral Myringotomy & Transtympanic Tubes)
   http://www.earcentergreensboro.com/medical-education/ear_tubes.php
2. Otitis media with effusion with Down syndrome
   Int J Pediatr Otorhinolaryngol. 2013 Aug;77(8):1329-32. doi: 10.1016/j.ijporl.2013.05.027. Epub 2013 Jun 20.
   In this study one in three eight-year-old children with DS had current middle ear fluid and had verified hearing loss.
3. Balkany, T.J., Mischke, R.E., Downs, M.P. & Jafek, B.W. (1979). Ossicular abnormalities in Down’s syndrome. Otolaryngology: Head and Neck Surgery, 87, 372-384. Middle ear fluid issues account for 83% of hearing loss in children with DS
4. The influence of eye movement and the vestibular-ocular reflex in reading and writing. Rev. CEFAC vol.16 no.6 São Paulo Nov./Dec. 2014 http://www.scielo.br/scielo.php?pid=S1516-18462014000601791&script=sci_arttext&tlng=en
5. The effect of otitis media with effusions on balance in children. Clin Otolaryngol Allied Sci. 2004 Aug;29(4):318-20. https://www.ncbi.nlm.nih.gov/pubmed/15270815
6. Ophthalmic complications of otitis media in child J AAPOS. 2011 Jun;15(3):272-5. doi: 10.1016/j.jaapos.2010.12.018.ren https://www.ncbi.nlm.nih.gov/pubmed/21777800

Reprinted by permission of The NACD Foundation, Volume 31 No. 9, 2018 ©NACD

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Jennie – 33 years old

9-28-2017

Six years ago my daughter Jennie and I moved to St. George, Utah from California. My daughter has Down Syndrome and was 27 years old and had been in special education classes all of her life. At this time I was introduced to the NACD organization and Sara Erling.

Jennie has been blessed to be able to be a beautiful dancer over the years. She has a natural ability to express herself on stage. I saw she was talented and that is was what I concentrated on for her during her growing years. She entered many dance competitions and danced with normal dancers. She has won many trophies.

During her growing years although her special education teachers cared about her and were wonderful dedicated people they did not have the skills to bring out the best in Jennie. Our special children can learn to read, can write their names, learn math and be of service to those around them. One of things I have learned from Sara is to keep my expectations high for Jennie.

Even though Jennie has this special talent for dancing when she started with NACD she couldn’t read, print her name, read words, do math, or talk in 3 to 4 word sentences.

Today she can read, print her name, read words, do simple math, and her talking has increased 75% especially in sentences. She plays the piano, learned to use an iPad and cell phone. Along with all of this academic growth has come her ability to do chores and to help me around the house or grocery shopping. Jennie loves to help. When she wakes up she gets herself dressed, says prayers and then starts on her chores. I never have to force her to do these things. Her chores are to put her dog outside for a potty break, pick up dog poop, empty the dishwasher, put our vitamins out on the counter for me to put together, prepare her favorite Crystal Light orange drink, take her vitamins, vacuum the whole house, and then start her NACD program that I have on her iPad. I do not have to force her or remind her to do any of these things. She is also wonderful about getting me things I need and never complains when I ask her to do that for me.

Jennie is now 33 years old and is continuing to grow, learning at a faster pace and that is all because of the NACD program. I see things all the time that are new that she can do. For example, we were in the car and I asked her something about stop lights. She paused and said “I don’t know” and I said “then I will teach you”. I watched her start her NACD program on her iPad and then asked her to do something for me. Her first thing on iPad is Smarter Kids and she sets the timer for how long she is supposed to do it. Since I interrupted her, I saw her go over and stop the timer so she would still get the right amount of time for her Smarter Kids program.

We are LDS (Mormon) and we are temple-going people. Not all Down Syndrome adults are capable of attending the temple and to do service in the temple, but because of Jennie’s growth and excellent behavior, she was approved for a temple recommend and we go every Wednesday. On a recent trip to the temple, I saw her multitask. She was reciting to me her testimony she had been memorizing, then on her own took out my wallet (which is broken), took off the rubber band and took out our temple recommends and then closed up my wallet, put the rubber band back on and put it back in my purse and during all of this never missed a beat practicing what she had memorized, which was her testimony of her faith. I am seeing things like this happen all the time and that is because her brain is growing. NEVER tell me that any of us are too old to learn and grow.

Concerning pets and our children, they are very important. Jennie was given a miniature Schnauzer dog and she has been like a therapy dog for her. She has helped in increasing Jennie’s ability to talk in sentences.

Our children can have many health problems. Jennie has had a hearing loss all of her life. Three years ago she was diagnosed with celiac disease. For three years now, she has been gluten free and it took three years to get her numbers down. In June she was approved for a cochlear implant hearing aid, but when they did another hearing test her hearing had improved by 75% and I feel that is because she has been gluten free for three years. She still has some hearing loss but will be reevaluated for the implant in December because she is borderline on needing it now. The doctors say she probably has had celiac most of her life and that Down Syndrome children tend to have celiac disease. The one thing I know is that anything we put in our children’s mouths can affect everything in their lives. When I was in the sound booth with Jennie this time, I saw that my daughter could hear.

In closing, I want to stress two things. First, our children are never too old to start the NACD program—never stop working with them. Second, for those with young children, do not give up. If I had done the NACD program with Jennie when she was young, I can only imagine where she would be today in what she could accomplish, but I am so excited with the progress she has made in the past six years.

ALWAYS KEEP YOUR EXPECTATIONS HIGH FOR YOUR SPECIAL CHILDREN

—Roberta McClellan & Jennie

A Note On Jennie….

 

I have had the privilege of working with Jennie and her mother Roberta since they started the NACD program six years ago. The biggest thought that comes to me when I think of Jennie is that it is never too late to improve one’s function, therefore significantly impacting their quality of life. Since being on our program, Jennie has come out of her shell. She is communicating and understanding so much more. As a result, she has been able to participate in her church and her community. Jennie is also able to take care of her mother. When they started our program, Roberta did everything at home, while Jennie was not able to help. Jennie has grown so much in her independence and her ability to not only take care of herself, but others. Roberta is amazing. At 80 years of age, she has worked so hard with Jennie to improve her function. She has learned to read and write, and be aware of what needs to happen in the course of a day. We opened Roberta’s eyes even more to the possibility of what can be and that if you put the right input in, with the right frequency, intensity, and duration, then the brain can change. 

For those of you that have adult children who live with you and whom you know need input, know that it is not too late. You can improve their life and your own.

 

—Sara Erling, NACD

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Are you tired hearing us talk about tympanograms yet? We’re not tired of talking about them or recommending that you get them yet. Obviously we’re not afraid to admit that we’re pretty opinionated on the subject of how significantly middle ear fluid can affect a child’s development.

For years there has been conflicting information by researchers regarding a correlation between speech and language delays/disorders and history of middle ear fluid. Studies that support each side are criticized by the other side for having design flaws, and nobody can seem to decide if having transient hearing loss (sometimes very frequently or else ongoing) and hearing a distorted speech signal affects how a child develops communication skills and phonology (speech sound development). A little common sense and some consideration of anecdotal data go a long way here. Because we’ve been at this business of observing and assessing lots and lots of kids for a very long time, we have some opinions on the subject. And because of these opinions, we frequently recommend to parents that they take their child for a series of tympanograms to see what the trend is over time with the status of their middle ears.

In the following article, pediatric audiologist Jessica Messersmith comes to the same conclusion when her own daughter regresses in language development during a period of ear infections. (It’s a short article and worth reading.)
http://leader.pubs.asha.org/article.aspx?articleid=2432364&resultClick=3

As she mentions in the article, the American Academy of Pediatrics supports the recommendation of ear tubes if fluid persists for three months. To really be proactive and collect strong data, tympanograms every two weeks over a three-month period is your best course of action.

That being said, as objective as tympanograms appear to be, here are a few points of caution:

• The established “normal” range may not apply to everyone equally. Our own observations in children with Down syndrome (one of the populations for whom this whole subject is especially critical) has been that many children have a tymp reading with compliance scores at the lowest end of the established (for the typical population) “normal” range. Because of history and functional observations, there has been a high suspicion of fluid in many of these cases. Some have had fluid confirmed when they had tubes placed and fluid was found (in spite of the tymp measurement). It raises the question of whether different norms might apply in this population. Or, as will be discussed below, whether kids with Down syndrome simply need to be tested differently due to their structural differences.
• In their chapter on tympanometry in Handbook of Clinical Audiology, Shanks and Shohet suggest that what is “normal” may vary by age and also by race. So again, as above, the current normative standards may not be valid for every individual.
• Some studies discussed that typical testing with the 226 Hz probe tone may not be an accurate assessment in the Down syndrome population. There was discussion of whether the 1000 Hz probe may yield more valid results.

That is all to say that even with something as seemingly simple and straightforward as a tympanogram, sometimes and for some kids, results need to be interpreted with caution. If all signs point to fluid issues and the tympanogram doesn’t support it, don’t just assume that your observations are wrong. Find a practitioner who will work with you and who is open to discussion and critical thinking and assessment.

References:

Messersmith, J.J. (2015). Eardrum Perfs and Language Spurts. The ASHA Leader, 20(9), 72.

Shanks, J. & Shohet, J. (2009). Tympanometry in Clinical Practice. In J. Katz, L. Medwetshy, R. Burkhard & L. Hood (Eds), Handbook of Clinical Audiology (6^th ed., pp. 157-188). Baltimore: Lippincott Williams & Wilkins.

Reprinted by permission of The NACD Foundation, Volume 28 No. 2, 2015 ©NACD

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Our own observations in working with thousands of children support the idea that chronic middle ear fluid can significantly impact a child’s processing, speech, language, intensity, and behavior. However, sometimes we are not aware that fluid is an issue until we begin to see some of these secondary effects. Some children may not show any outward behavioral signs of fluid unless it accompanies an actual ear infection. Sometimes fluid goes undetected until we begin investigating possible causes of a child’s speech delays.

Diagnosing middle ear fluid is a simple process. An audiologist or ENT will attempt to view the child’s eardrum with an otoscope to look for signs of fluid or inflammation. Then she will use a quick, objective diagnostic tool, tympanometry, to assess the function of the middle ear. To obtain a tympanogram, all that is required is that the child sits still for a few seconds while a probe is placed in the ear canal. The audiologist or ENT will interpret the test results and be able to identify whether or not the middle ear is functioning normally. Keep in mind that the tympanogram only gives information regarding middle ear status at that point in time. Therefore it may be necessary to have several tympanograms periodically over a few months in order to determine whether chronic fluid is present.

If you determine that your child does have chronic middle ear fluid, a common treatment is the placement of tiny tubes into the eardrum, or tympanic membrane. The tubes allow the fluid to drain and for the pressure to equalize on either side of the eardrum. Tube placement is a simple same-day surgical procedure, requiring brief general anesthesia. Sometimes the procedure must be repeated if the tubes fall out prematurely and the child still has fluid problems. After the tubes fall out or are removed, the tympanic membrane usually heals by itself, and no further intervention is needed.

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“Can you hear me now?” “What did I say?” “Are you listening to me?” “Please just say ——-.” “Say dog/ horse.” “Read my lips.” At NACD we have been working on all of the pieces of the puzzle that help your children learn and develop. All of the pieces are not necessarily easy to test, identify, or treat. Most of those working within the field don’t worry about identifying what is actually broken; they just give it a label. “Sorry, your child has a central auditory processing disorder.” “Your child is apraxic.” “Sorry, your child is MR.” “Have you considered sign language?” At NACD we do not find a label t use as an excuse; we look for the cause of the problem and treat it; and historically, if a treatment doesn’t exist, we create one.

Some of the most difficult areas we have to address are those pieces involving hearing, the condition of the middle ear, tonal processing, auditory sequential processing, speech, oral motor function, and language. The first critical piece in this developmental chain is hearing. One would think that at this point in time testing and understanding hearing would be a simple thing. Not only is it not simple, but it often can’t be done, or at least can’t be done well. (Our team at NACD is presently working on some exciting new ways to actually see what a child hears and processes as part of our new TSI –Targeted Sound Intervention)

Without being able to obtain reliable, accurate data, we sometimes have to rely on what Bob refers to as the “Black Box Protocol.” The Black Box Protocol basically says that if we cannot measure or definitively know what is going in, we can surmise what is going in by looking at what is coming out. In a great movie, “Never Cry Wolf,” a scientist is sent to the Yukon to determine if the wolves are responsible for a decrease in the caribou herds. The scientist, unable to actually see what the wolves eat, examines the wolves’ scat and learns that the wolves are actually eating mice. This is the Black Box Protocol–look at what is coming out, and you can get a reasonable idea of what is going in. To determine what your children are hearing or processing, we don’t need to examine their scat. But we do need to look at their ability to understand and produce language. In the case of receptive and expressive language, if we have a problem with what is coming out, we likely have a problem with what is going in. So, how do we improve what is going in? One thing we can do is to improve the quality of the sound/speech that the child hears, as well as to control the extraneous sound that distorts and masks what we are hoping our children are taking in.

If your child has listening and auditory processing difficulties, your evaluator may have recommended or will be recommending an FM system on your program. FM systems (or “auditory trainers”) have historically been used in school classrooms for students who have difficulty hearing in the presence of background noise. The teacher speaks into a microphone, and the student hears her voice through headphones, blocking out the distracting sounds of the classroom.

In many instances we have found FM systems to be useful at home as well, as they provide direct input to a child’s ears during program activities or in daily communication. This eliminates the competing sounds of the environment and provides more intensive, appropriate input to your child. For a child with processing or hearing difficulties, the direct input can make a significant positive difference, making processing easier and program more effective.

The biggest obstacle we have had in recommending FM units to our families has been cost. Because they are usually sold to schools, systems are quite expensive, generally around $2000. For this reason NACD has put together a variety of systems that are now available to you. The systems contain wired and wireless mics, as well as wired or wireless headphones, along with all the necessary mixers, cables and instructions. We have managed to find components that all provide excellent sound quality at really affordable prices. The pieces of the system are high quality and should last well with frequent use.

We are excited to be able to provide these FM units and are anxious to start seeing the results. If you have any questions please do not hesitate to call me at the National Office 801-621-8606.

Please contact the main office or see below for further information or to order:

Click here to view all FM Units currently available at the NACD Store

NACD Newsletter, Volume 1 Issue 9, 2005 ©NACD

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The current study was intended to look at the effectiveness of using TSI: Focused Attention with adults whose main complaint was difficulty hearing and understanding when there is background noise.

Method

Fifteen participants completed the study. NACD client families were contacted about the study, so participants were either parents or grandparents of children involved with NACD. Criteria for inclusion into the study included:

• Age 40 or older
• Complaint of figure-ground processing problems, with or without a documented hearing loss

Figure-ground processing problems were explained to potential candidates as concerns related to processing, hearing or listening when there is background noise.

Participants were provided with a TSI: Focused Attention program and headphones. They were instructed to listen twice per day, 5 days/week, for a total of 24 weeks. Pre- and post-testing included a speech-in-noise test and rating scales.

Participants were divided into two groups:

• Hearing loss—either documented or suspected but never tested (N=9)
• No hearing loss (N=6)

Regardless of grouping, all participants used the program the same way and received the same instruction and testing.  The speech-in-noise test administered was an informal assessment created by NACD. It consisted of a CD of 20 words spoken in quiet (to serve as a comparison), randomly alternated with 20 words spoken in noise. Listeners were asked to repeat each word they heard.  In addition, participants were asked to rate eight listening/processing skills 0-10, with 0 meaning they had no difficulty with that task and 10 meaning they had the greatest difficulty. Skills on the rating scale are listed in Table 1.

Results

Results are reported in Tables 2 and 3 and are reported separately for the Hearing Loss group and No Hearing Loss group. Results are shown as percentages correct for the speech-in-noise test. For the rating scales, results are shown as the mean score for each question.

On the speech-in-noise test, percentage of accuracy increased after the program, although the increase was much greater for the No Hearing Loss group than the Hearing Loss group. On the functional rating questionnaire, most ratings by the listeners in the Hearing Loss group decreased after the program, indicating a perceived improvement in function. For the few questions that showed a higher post-rating (implying worse function), some possible factors can be found in the Discussion section.

As part of the post-program interview, participants were asked about if they felt they benefited from the program, their enjoyment of the program, and whether they’d recommend it to someone else. Results are reported in Table 4.

Discussion

Results suggest that the normal hearing adults who experience difficulty with figure-ground processing may benefit from auditory training using TSI: Focused Attention. Adults who have issues with figure-ground processing due to hearing loss may be less likely candidates for the program.

One factor that the scores of the speech-in-noise noise test do not reflect is the accuracy—or, more aptly, the degree of inaccuracy—of incorrect responses. In many cases, some responses on the post-test were incorrect, yet closer to the correct answer than they were on the pre-test. If scores could reflect improvement in the accuracy of incorrect responses, the results would have reflected more change than they did only looking at correct vs. incorrect.
Although the numerical values in the tables in the Results section are interesting, perhaps even more significant are the comments made by the listeners about their perception of functional change with use of the program (see Appendix 1). Even listeners with hearing loss commented on how they felt their listening skills had improved. So test scores should be interpreted with caution, as the scores on the tests could be influenced by a number of factors. Some participants admitted that on the functional rating questionnaire they may have been thinking about the questions differently on the post-test compared to the pre-test. Others felt certain that for both the speech-in-noise test and the post functional questionnaire, they were more aware of their own skills and efforts and may have tried harder. A complete list of quotes and comments can be found in Appendix 1.

Besides the scores and listeners’ comments about change, other outcomes were also worth mentioning. Two of the participants reported that family members wanted to do the program because of the change they noticed in the listener. In addition, because of their positive experience with TSI: Focused Attention, 14 of the 15 participants wanted to go on to participate in the second research study, which looked at the effectiveness of TSI: FA2 for adults, a language-based figure-ground program. The one participant who declined participation in the second study said she only did so due to the logistics of her current schedule. Additionally, 100% of participants who responded to the question said they enjoyed doing the program; most felt they benefited from doing it; and most would recommend it to someone else.

Conclusion

It is often the case that efficacy studies such as this raise more questions than they answer. For this reason, almost all “conclusion” sections include the statement, “More research is needed…” And we concur with that thought, especially in light of the small number tested in the current trial. At the same time, understanding the limitations of the current study, we suggest that the results imply that TSI: Focused Attention can benefit adults who experience difficulties with auditory figure-ground processing, and that adults with normal hearing are better candidates for the program than those with hearing loss.

Appendix 1

54 y.o. male with hearing loss: “[It] helped me concentrate on what I was listening to, even though it didn’t help my hearing. I learned to focus, although my hearing problem still seems to be getting worse.”
52 y.o. female: “…I feel like I’m better able to focus.”
71 y.o. female: “As to whether or not it will help in everyday life, I’m not sure yet. But I definitely felt it was worth doing.”
61 y.o. female with hearing loss: “I get nervous going places with friends where I think there will be background nose. The last time I went, it was better than I thought it would be [post-program].” “[The program] helped me work harder at paying attention in conversations.”
41 y.o. female with suspected hearing loss: She reported that after the program she no longer became agitated and frustrated when all of her kids were talking. “It’s been great! My husband wants to do it.”
41 y.o. female who had some rating scores increase on the post-test: “It’s not worse; I’m just paying attention to it more.”
42 y.o. female: In regard to ratings that increased, she felt it was due to being more tuned in and aware of what she’s hearing and what she’s missing. Other comments: “I can turn the volume on things down now.” “I have my kids repeat less.” “I’m still distracted by other people’s conversations, but it’s a little better.”
42 y.o. female: “[After the program] I find it easier to listen in public when someone’s talking to me and there’s others around. I think I’m more focused on who I’m with.”
63 y.o. male with hearing loss: In regard to a functional skill he rated as higher (i.e. worse) after the program: “I don’t think I’m actually any worse than before. I may be doing better; I may be more aware now.”
68 y.o. female: Reported she was able to concentrate better and had less frustration with background sounds after the program. “My focusing has improved.”
64 y.o. female with hearing loss: “[My] awareness has changed. I’m more aware of what I’m missing now.”

Reprinted from the Journal of The NACD Foundation (formerly The National Academy for Child Development)

Reprinted by permission of The NACD Foundation, Volume 27 No. 3, 2014 ©NACD

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Hear: \ˈhir\
transitive verb 1: to perceive or apprehend by the ear 2: to gain knowledge of by hearing 3 a: to listen to with attention : HEED b:ATTEND <hear mass> 4 a: to give a legal hearing to b: to take testimony from <hear witnesses>intransitive verb 1: to have the capacity of apprehending sound 2 a: to gain information : LEARN b: to receive communication <haven’t heard from her lately>

And yet this was one of the most difficult areas of my journey with Sam. Sam was born with Down syndrome, in his first year he suffered a brain injury due to oxygen deprivation which manifested itself with weakness on his right side. He was diagnosed with dysphagia and Apraxia. These areas of diagnosis were pretty easy to get. However, the diagnosis of hearing loss was not so easy.

From early on my gut feel was that Sam could not hear well. When I questioned his ENT he immediately agreed to a hearing test however Sam did not cooperate with most of it but he did react to some sounds so they indicated that his hearing was in the normal range. For a while I let the subject drop but it still nagged at me. Sam learned to read and began to speak although much of his speech was cued from his reading but he rarely answered questions correctly and had a great deal of difficulty picking up on new words unless he read them first. I felt a great deal of his frustration stemmed from him not being able to hear well.

I went back to his ENT and he suggested we do an ABR hearing test. I was hoping this would finally confirm my gut feeling, however, we were told that the testing showed that his hearing was normal. My Mom and I even questioned the doctor asking if he didn’t have Down syndrome or his other issues would his hearing be in the normal range? Often times I have been told my medical professionals things such as “Sam’s muscle tone is good”…however they forget to add the statement for a child with Down syndrome.

Our Wisconsin Chapter of NACD opened and Bob Doman came to do the first set of evaluations. He watched Sam for quite some time and then said to me, “Sue, I don’t think he can hear well.” I wanted to hug him, I finally had someone who agreed with my gut feel about Sam. I now felt a renewed drive to get Sam the help he needed.

I went back to my ENT and again questioned Sam’s hearing. He checked for fluid in Sam’s ears and asked me about ear infections. The majority of Sam’s tympanograms were normal and he only had 2 ear infections since his birth. It was at this point that our relationship took a slight turn down the wrong path. I began to hear statements like, “Well, Sue you have to realize he has Down syndrome and Apraxia so that is why he is having difficulty understanding and speaking.” “We can do another hearing test but it probably won’t show anything.” “I think your gut feel is incorrect and stems from his other issues that are causing your concerns.” I just wanted to scream, “WHATEVER!!…you’re not listening to me…I want him to hear.”

I asked about a trial hearing aid but was told that it could possibly damage his hearing instead of helping him. I purchased a personal FM system to use with Sam but he didn’t like wearing the head set. I worked with Sam using a karaoke machine with some success with new words. I then started the Listening Program with the bone conduction head set. I had done the Listening Program previously but didn’t see the effect that other parents talked about.

The bone conduction system was different…Sam’s speech increased and we finally went up another level in his auditory processing. Now I was getting excited. I went back to his ENT to tell him what I was seeing but he was stuck in the old responses and didn’t feel this had to do with Sam’s hearing. I asked him about a trial bone conduction hearing aid and I was told that he wouldn’t even consider it until we made sure Sam’s issue wasn’t with fluid. I said, “Fine, let’s put tubes in and that will take care of any fluid”. The ENT said Sam’s tympanograms didn’t show enough fluid to warrant surgery. I was up against a wall and unfortunately Sam was the one who was suffering. I prayed and I started searching for a different ENT although in our area Children’s Hospital is the easiest to work with in regards to Title 19.

I went to a conference and heard Dr. Andrew Hotaling an ENT from Loyola University speak about children with Down syndrome. He seemed to get it and I decided to take Sam to see Dr. Hotaling and he agreed to have tubes put in. I wish I could say that when the tubes were in we saw a remarkable change in Sam…but we didn’t. Dr. Hotaling’s office attempted to do a hearing test with Sam but after the two hour drive down to the office and his normal appointment, Sam again decided not to cooperate.

We returned to Sam’s original ENT. Needless to say he was amazed that Sam had tubes and when I again asked about a bone conduction hearing aid he said “Fine, have him do another round of hearing tests but I don’t think it will do any good”.

On my way to meet with the audiologist I prayed. I told God that this has been a 3 year journey and if I am on the wrong path, please let this appointment decide it and I will move on. I met with the audiologist and explained Sam’s history. I also explained how we have not had much luck getting Sam to cooperate in the booth. I told her about my experiences with the bone conduction headphones and the difference in Sam that I had seen. We worked out a plan so that as soon as Sam came into the office he would go right to the booth, no waiting time. I also stayed in the booth with him to help keep him engaged in the task and to help alleviate his frustration.

I held my breath as we started the test. Sam was cooperating…I was thanking God…and in a very short period of time it became evident that there were certain sounds that Sam did not hear. We then tried a bone conduction band on Sam which took some time to get him to cooperate with, but when we repeated the test he did better. I waited until we came out of the booth and the audiologist finally said the words I had been waiting to hear, “Sam has a conductive hearing loss in both ears”. I hugged her, thanked God and finally felt at peace. Most people would not get excited when they find out that their child has a hearing loss but I had waited for so long for someone to finally confirm my suspicions…I was thrilled.

Sam received a demo bone conduction hearing aid. I was so excited to tell Ellen, Bob & Lori Riggs that Sam finally had a hearing aid. However, I was concerned on how I would get Sam to wear the hearing aid since he has a lot of sensory issues about his head. Ellen assured me that if he can hear he will wear it. The demo hearing aid came with a band and Sam quickly learned how to remove it and boomerang it across the room. I was discouraged but decided to continue working with him and ordered a baseball hat that the hearing aid could be connected to. When the hat came it was easier to keep the hearing aid on and he could adjust it himself…he wore it and he was happy.

The changes in Sam began at that point…I often asked Sam “Where did we go on the airplane”…Sam would say “High up, in the sky”. After receiving his hearing aid, I asked him again and he stopped, scratched his chin, and said “Hmmmm….Mexico”. When he answered correctly it brought tears to my eyes and I said to myself, it is in there, he does know…it’s not the Down syndrome or the brain injury…he just couldn’t hear. We saw more and more changes when he received his brand new Baha Divino Bone Conduction Hearing Aid. One morning as I was cleaning up the kitchen I dropped a plate…Sam came running in and said, “OH…..MY….GOD”. Knowing I had never fast flashed that phrase, I asked him where did you hear that? He told me “iCarly”, the Nickelodean show he was watching the previous evening. This was amazing because Sam didn’t usually pick up on auditory phrases.

Now it would be great if I could tell you that the hearing aid has him speaking clearly and always answering questions correctly…but I can’t. I have learned with Sam that there is no quick fix…but instead pieces of a very complex puzzle. The hearing aid is an answer to my prayers and is yet another piece of the puzzle to help Sam reach his full potential. We are still working on active listening, a trait none of the males in my home seem to have??? We are re-inputting words to help Sam hear them correctly and we are actively working on daily directions to allow Sam the experience of hearing and following instructions. Sam is learning turn taking, allowing him to stop and listen, think and then respond. We still have a long journey ahead of us but we are again moving forward and making progress in areas we seemed to have stalled on. Sam’s frustration during doctor appointments, haircuts, and dentist appointments has been reduced as we are now able to explain and talk him through these situations. He is becoming more confident in speaking to people outside the family and his vocabulary is again expanding now from words he has heard instead of words he has read.

My current favorite game is to pick a task…like making breakfast and having Sam talk me through it. Now with his hearing aid, I can ask him where the eggs are and he says, “In refrigerator”. I then get them and put them on the stove. He says “No, Mom..get a pan”. I then put the eggs uncracked into the pan, he says “No, Mom…open them” and so on. Previously we would not have been able to do this because he would have given up on conversing or would have found in too difficult to follow my lead.

When I started with NACD…I wanted one thing more than anything else. I wanted to be able to have a conversation with Sam. With the addition of the hearing aid I now feel closer to that goal and that we are finally on the right path. I still get very excited every time he takes his pointer finger next to his ear and says “Sound?” and I say, “What is that sound”, he listens and he answers me.

Going back to the definition of the word hear, I am so excited that Sam now has the opportunity to:

gain knowledge of by hearing, to listen to with attention, to gain information : LEARN

Life is good!!

Reprinted by permission of The NACD Foundation, Volume 22 No. 8, 2009 ©NACD

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At first glance an audiogram may look simple and straightforward. Delving into interpretation and implications of the audiogram, however, leads to a whole different picture: the mysterious world of audiology. As many more parents have been sending me their child’s audiological reports to try to make sense of them, I have become acutely aware of how little parents are being educated by their audiologists regarding what they are testing, what the results mean, and why their audiologists make the recommendations that they do. It’s not a simple matter of reading over the report that the audiologist writes. This is the reason I frequently pass along your reports for interpretation to my “audiology guru,” a university professor of audiology. As a speech/language pathologist, there are many finer points to hearing tests that I do not understand nor am able to identify. As an expert in the field, my audiology colleague looks at all of the pieces, reads between the lines, and gives me valuable insight to pass along to you. Ideally, this is information that you should expect your audiologist to be providing to you. However, as it seems that this is not often happening, it becomes more important that you press your audiologist to answer your questions. Being able to ask questions requires that you have an idea of what you are asking about.

Because hearing tests seem to be such an area of misunderstanding, yet are often a vital piece of information when trying to understand our children’s issues, I thought it would be useful to provide you a few basic definitions and explanations of the different hearing tests that you are most likely to encounter. For the purposes of this article, I will not get into the realm of interpretation of results. I will simply explain what the tests are.

Audiogram

The audiogram is likely the most familiar hearing test to you. The audiogram is a graph representing at what loudness levels (measured in decibels, dB) a person hears tones of different pitches (measured in Hertz, Hz). Typically, the audiologist plays the tones from an audiometer to headphones so that the right and left ears can be assessed separately. However, for very young children or children who are not readily cooperative with headphones, audiologists often test them in the sound field. This means that the audiologist presents the tones to the child through a loudspeaker in a sound booth and then watches for a visible response from the child suggesting she heard the sound. If the audiologist notes responses, she will write them on the audiogram; however, she will not be able to determine if the child heard the sounds with only one ear or both.

Audiometry often includes testing with bone conduction, masking, and speech recognition. These tests give the audiologist more information about the severity and types of hearing loss. For the sake of the present article, I will not elaborate on the specifics of these aspects.

The human ears of most children can hear frequencies up to 20,000 Hz. Although our speech sounds fall within a rather limited range within these 20,000 frequencies, hearing the intricacies of language and adequately perceiving the world around us depends, in part, upon properly hearing the full range of sound. Even so, a typical audiologist tests about four to six different frequencies in each ear (covering about the pitch range of a piano); though some audiologists test a few more. So, how comprehensive can a test be that gives us a snapshot of how we hear only a handful out of 20,000 frequencies? This sample of frequencies does leave some gaps; especially if the audiologist does not also test how well a child can detect and understand speech.

A potentially greater limitation of the audiogram lies with the audiologist’s training and skill in performing behavioral hearing testing of children who are very young or who have developmental disabilities. My impression, as well as that of my audiology colleague, is that some audiologists give up too quickly when a child is labeled as “difficult to test:” the child may cry or will not initially volunteer a response to sound. A skilled audiologist will be patient, work more creatively with the child, or try testing the audiogram again within the next week. Some audiologists, however, recommend the child be retested a few months later when he is more mature. Other audiologists may recommend the child have a different hearing test, like auditory brainstem response testing (abbreviated ABR or BERA). As discussed later, these tests usually are more expensive than getting an audiogram and often require that the child be asleep or sedated. Patience, perseverance, and a little imagination will often yield valid audiograms on most so-called difficult-to-test children and make other, more expensive tests unnecessary.

Tympanograms

Tympanometry is a quick, easy way to assess the status of the middle ear behind the eardrum. An audiologist obtains a tympanogram by placing a probe in the ear canal for a second or two. It takes measurements such as the volume of the middle ear and the movement of the eardrum. A tympanogram does not tell you directly how well your child hears soft sounds or understands speech. However, it is an important test because the results indicate whether or not the middle ear is functioning normally. Certain results suggest fluid is in a child’s middle ear. That is why many of you have had your evaluator recommend that you take your child for a series of these simple tests.

An important point to keep in mind is that a tympanogram provides you with information about your child’s middle ear at the moment the test was performed. If you wish to rule out the possibility of chronic fluid that may have gone undetected, you need to have several tympanograms done at specified intervals (for example, every two weeks for 2-3 months). This will give you a better idea of what is happening with your child’s middle ear over time.

Otoacoustic Emissions (OAEs)

Another commonly and easily used measure of hearing are OAEs. OAEs are sounds produced by the cochlea (also called the inner ear) in response to a sound. Sounds are presented through a microphone in a probe in the ear canal. The sound passes through the middle ear, and into the cochlea (also called the inner ear). Tiny hairs in the cochlea produce a sound echo in response. The audiologist measures this echo from a microphone also in the probe in the ear canal.

Normal OAEs imply normal function of the outer hair cells of the cochlea. However, because the sound has to travel through the middle ear before it is measured in the ear canal of the outer ear, absent OAEs may or may not indicate a problem with the cochlea. If there is a problem with the middle ear, this can reduce or remove the echo. This is a good example of why audiological test results must be looked at as a big picture, not simply in individual pieces. Assessing the tympanogram in conjunction with the OAE makes the results of OAE testing more clear and meaningful.

Acoustic Reflexes

Acoustic reflexes are contractions of tiny muscles in the middle ear: the stapedius and the tensor tympani muscles. Acoustic reflexes normally occur in the presence of loud sounds. That is, the ear has these protective reflexes to dampen loud sounds and thus protect the cochlea from damage. Audiologists typically test acoustic reflexes immediately after obtaining tympanograms. As with tympanograms and OAEs, acoustic reflexes are measured through a probe in the ear canal. They are easily and quickly measured when a child is quiet. The absence of acoustic reflexes often during testing suggests a problem with the middle ear, the inner ear, or the auditory nerve.

Auditory Brainstem Response (ABR)

ABR is a hearing test mainly used for screening hearing of newborns. ABR is used with older children when the audiologist is unable to obtain valid information by an audiogram. As suggested earlier, a complete ABR test of “difficult-to-test” children is relatively expensive and too often over-used. A child must not move much when administering the ABR; accordingly, the child usually must sleep naturally or be mildly sedated during the test. A series of clicks is presented to each ear through earpieces inserted into the ear canals. Brain wave activity is then measured in response to the clicks. Because ABR requires no visible response to sound on the part of the child, it is not considered to be a behavioral hearing test like an audiogram. That is, ABR provides an indirect estimate of the individual’s hearing level and usually yields less information about a child’s hearing than a valid audiogram.

Audiology is complex field that requires the ability to look at different diagnostic tests together in order to adequately assess a child’s hearing. You cannot expect to understand all there is to know about interpreting your child’s hearing test results; I certainly do not. If your audiologist does not provide you with adequate education, you must take the initiative and ask as many questions as you need to understand the meaning of your child’s hearing tests. You must also ask about the rationale when your audiologist makes recommendations for additional testing. The more informed you are, the better equipped you are to make decisions regarding what your child really needs.

Before seeing an audiologist, think through the questions that you might want to ask him/her. What do you want to know? Write your questions down and take them with you. I am including some possible questions here that you may want to include; but be sure you get the information that you want to know.

1. What type of tympanogram does my child have?
2. What does the tympanogram suggest?
3. What is my child’s hearing threshold in the right ear? Left ear?
4. If he/she has a hearing loss, what are the best options? (ex. FM system at school; FM system at home; hearing aids; preferential seating; other suggestions)
5. Are additional tests being recommended? If so, what do they test? How would this additional information be helpful?

Reprinted by permission of The NACD Foundation, Volume 21 No. 10, 2008 ©NACD

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