Anjum Bano Kazimi
ABSTRACT:
ABSTRACT:
This study is bassed on the assumption that parents are aware about the auditory performance of their children with
hearing impairment, who are receiving speech therapy services regularly either their at own schools or in any clinical setting. The sample was drawn from five special schools of Karachi. Fifty parents whose children are receiving speech therapy were selected through purposive sampling with the help of the concerned teacher. The instrument was a structured questionnaire containing twenty items related to the topic, applied on both sexes. Results indicate that parents severely lack information regarding their children’s perception about localization, identification and auditory discrimination of sound. It was suggested that special training should be provided to the parents as well as their children with special needs, to use their hearing ability more effectively.
INTRODUCTION:
The term Hearing Impairment (HI) applies when defective functioning of the auditory system may be measured using physiological or psycho-acoustical techniques (e.g. audiometry) and the defect is expressed as a worsening of pure tone thresholds (EU Work Group 1996)[1]. The terms hearing disability, handicap, hearing handicap and deafness should be avoided as semantic equivalents to HI, as these have diverse meanings and definitions in different socio-cultural contexts (Davidson et al. 1989).[2]
The assessment of HI aims at classifying the type, degree, configuration, aetiology and time of onset of the impairment, although especially the latter can often be difficult to determine. HI is usually considered prelingual when it begins before the age of two years (Parving & Christensen 1993[3], Paul & Quigley 1994[4]) and postlingual when it begins after the most active period of speech and language development, i.e., after the age of five years (Lucks Mendel et al. 1999)[5]. Preilingual HI is considered to have its onset during the active period of speech and language development, between the ages of two to five years, although HI is sometimes defined as postlingual when it begins after the age of two years (Paul & Quigley 1994)[6]. Children are usually considered to have acquired most of the phonological rules of their language by six to eight years of age and most of the semantic rules by the age of four to five years (Ingram 1989[7], Crystal 1990[8]), which clearly points to a difficulty in the division into prelingual vs. postlingual HI. When HI develops in adult life it may be classified as acquired (Martin 1982)[9], regardless of the aetiology, i.e. this may include both hereditary and congenital conditions (Morrison 1993)[10]. Postlingual HI will be taken here to refer to the onset of severe or profound HI after the age of five years.
According to the changes occurring in the functioning of the hearing organs, HI can be classified as conductive, sensorineural and combined/mixed. Conductive HI is the result of a failure in sound conduction, i.e. attenuation caused by a disease in the outer and/or middle ear. Conductive HI cannot exceed 60 dB, and according to a proposal by the EU Work Group (1996)[11], the bone conduction thresholds (BC) in conductive HI are normal (< 20 dB), but the air conduction (AC) thresholds are > 15 dB worse than these when averaged over frequencies of 0.5, 1 and 2 kHz. HI is classified sensorineural (SNHI), when the defect is located in the cochlea (sensory) and/or along the auditory nerve and brainstem (neural). No appreciable air-bone gap between the AC and BC thresholds is present in SNHI (less than 15 dB averaged over frequencies of 0.5, 1 and 2 kHz), and both AC and BC thresholds are poorer than normal (worse than 20 dB HL) (EU Work Group 1996)[12]. Mixed or combined HI is a combination of the features of both conductive and sensorineural impairment, the BC thresholds being worse than 20 dB and the gap between the AC and BC thresholds being > 15 dB averaged over frequencies of 0.5, 1 and 2 kHz (EU Work Group proposal 1996). HI can be classified as central when referring to dysfunction of the central auditory nervous system (Silman & Silverman 1997)[13].
Uniform definitions of the degrees of HI are important for both research and clinical purposes (ASHA 1998)[14], but several classifications have been presented during the past decades. The definitions put forward by the World Health Organization (WHO) (1991)[15] and the EU Work Group (1996)[16] are currently in widespread use in research and clinical practice, the latter being based on the earlier proposals of Liu and Xu (1994)[17] and Parving and Newton (1995)[18] (Table 1). The recent definition proposed by the EU Work Group (1996)[19] differs from an earlier one by the British Society of Audiology (1988) mainly in the frequencies included in the calculations, and these two differ from the WHO (1991)[20] definition both in the frequencies and the degrees of average impairment. The aim of the EU Work Group proposal (1996)[21] has been to obtain better uniformity and to improve the interchange of information, because variation in the definitions can result in differences in prevalence, for example, which can also affect the estimated need for rehabilitation services (Uimonen et al. 1997[22], Duijvestijn et al. 1999[23], Uimonen et al. 1999, Smith 2001[24]).
Table 1 Three Classifications of the Grades of Hearing Impairment
| Grade of Hearing Impairment | British Society of Audiology (1988) PTA0.25–4kHz | WHO (1991) BEHL0.5–2kHz | EU Work Group (1996) BEHL0.5–4 kHz |
| Mild | 20 – 40 dB | 26 – 40 dB | 20 dB < x < 40 dB |
| Moderate | 41 – 70 dB | 41 – 60 dB | 40 dB ≤ x < 70 dB |
| Severe | 71 – 95 dB | 61 – 80 dB | 70 dB ≤ x < 95 dB |
| Profound | > 95 dB | ≥ 81 dB | x ≥ 95 dB |
x = BEHL0.5–4 kHz.
HI can affect people’s lives at many levels of functioning, and the effects of impairment on ability to perform activities or fulfill social roles are individual in nature (Arnold 1998)[25]. The International Classification of Impairments, Disabilities and Handicaps (ICIDH, WHO 1980)[26], which was aimed at defining the terms impairment (body level), disability (person level) and handicap (society level) and finding a consensus on the categorization of their domains, succeeded in classifying the previously ambiguous terminology regarding audiological measurements, but could not establish any clear consensus in the terminology (Stephens & Hétu 1991[27], Arnold 1998[28]). The recent version of the International Classification of Functioning, Disability and Health (ICF, WHO 2001)[29] outlines revisions to the original ICIDH classification and replaces the former definitions of impairment, disability and handicap with ones that refer to body functions and structures, activities and participation, and contextual factors of an environmental and personal nature. It presents a model in which the relationship between the primary dimensions of disabilities is considered interactive and it is acknowledged that changes in one dimension can potentially influence other dimensions. It also aims at taking into consideration the complex interaction between physical and psychological factors on the one hand and social, environmental and personal factors on the other.
Table 2 Degree of Hearing Impairment and its Effects
| Amount of Hearing Loss (dB) | Type | Effects |
| 26 – 40 dB HL | Mild | Many have difficulty in hearing faint or distant speech. Without audiological management, a child who experiences a 35-dB hearing impairment may miss 25% to 40% of the speech signal depending on the noise level in the room and the distance from the speaker. Without the use of hearing technology, the child who has a 35-dB to 40-dB hearing impairment may miss up to 50% of class discussion. |
| 41 – 55 dB HL | Moderate | A child with hearing impairment at this level may miss 45% to 75% of speech signals and without the use of hearing aid technology and intervention, the child is likely to have limited vocabulary and imperfect speech production. |
| 56 – 70 dB HL | Moderately Severe | If amplification technology is not used, spoken language must be very loud and the speaker is preferred to speak very close to the child. If the child does not receive appropriate early and continuing intervention, s/he will have marked difficulty in school and there will be evidence of speech unintelligibility and delayed language development. The child may also have problems with social behaviors. |
| 71 – 90 dB HL | Severe | Without hearing aid technology, it will prevent a child from hearing all conversational speech. One may still be able to hear vowels but it will be difficult to perceive consonants. |
| 90 dB HL and above | Profound | A person with profound hearing loss cannot hear any sounds without amplification. |
Normal hearing is essential for effective communication and interaction with our environment via the auditory modality. Impairment in "hearing" impedes our ability to understand the spoken message and/or listen effectively. To most, hearing refers only to the ability to perceive sounds. True hearing involves not only the physical ability of the ear to detect sounds, but to the ability to integrate and assimilate the acoustic information in our environment. Auditory processing enables "sound localization and lateralization, auditory discrimination, auditory pattern recognition, temporal aspects of audition including temporal resolution, temporal masking, temporal integration and temporal ordering; auditory performance with acoustic signals and auditory performance with degraded acoustic signals." (ASHA 1996, p.41)[32].
Physiologically, auditory stimuli i.e. sound reaching the cochlea, are encoded and transmitted along neurological pathways. Interactive brain/neural networks assimilate the information from multiple sources to interpret the pattern of acoustic stimuli and ultimately the message. Inaccurate/incomplete coding or transmission of the acoustic signal may result in aberrant processing of the auditory information. An auditory processing deficit refers to impaired function in one or more of the above noted auditory processes.
Recent research has postulated three different types of neurophysiological deficits which underlie childhood auditory processing disorders:
- Neuromorphological disorder (areas of underdeveloped, misshapen and/or misplaced cells in the left hemisphere or auditory areas of the corpus callosum). This group represents 65-70% of those diagnosed with CAPD;
- Maturational delay of the Central Auditory Nervous System (25-30%); and
- Neurological diseases, disorders and insults (less than 5%).
In addition, it can co-exist with many other conditions including hyperlexia, Attention Deficit Disorder, language impairment, learning disabilities, dyslexia, autism, PDD, aphasia and/or children with a history of chronic otitis media[33].
Children with auditory processing disorders frequently try very hard to understand the spoken message and become confused, angry and/or frustrated when they are unsuccessful. Many children with auditory processing difficulties suffer from psychological “burn out” over time. Sustained academic failure, strained peer and family relationships, and pronounced frustration may result in depression. Some children grow to dislike school, exhibit low self-esteem, socially withdraw, or act out. Early identification and appropriate intervention may prevent some of these unfortunate results. All of the above points will be exacerbated by the presence of other conditions i.e. language impairment.
In conclusion, for a child, hearing and speech are essential tools of learning, playing and developing social skills. Children learn to communicate by imitating the sounds they hear. If they have a hearing loss that is undetected and untreated, they can miss much of the speech and language around them. This results in delayed speech/language development, social problems and academic difficulties.
OBJECTIVES:
Purpose of the study was to find:
· Whether parents of children with hearing impairment are aware about the auditory performance of their children or not?
· Whether parents take part in the development of auditory domains (understanding, identifying, localization and differentiation of sound of their children).
METHODOLOGY:
Through purposive sampling method, parents of children with hearing impairment were selected from the five non-government schools of Karachi. Selection of the sample was done by the help of school teachers and they found parents’ acceptance through a consent letter.
The instrument of the study was a structured questionnaire and divided into two sections. The first section included general information like age, sex, number of children, number of special children & their severity of the impairment etc. Second section was collected relevant information about the theme of the study. The draft of the questionnaire was pre-tested for necessary modification. The researcher personally observed those children to verify information provided by the parents about whom research data was collected. Information related to auditory skills of special children was covering domains of the following auditory skills:
- Sound perception or awareness of environmental sound in both quiet surrounding or in noisy surrounding.
- Attention or focus given to meaningful sounds in both quiet and noisy surrounding.
- Localization of the source of sound both in quiet environment and in noisy environment.
- Discrimination of sounds both in noisy as well as in quiet surrounding.
FINDINGS:
The findings of the study are given below:
- The largest number of respondents 80% replied that their child could not respond in noisy environment while 50% sound that their child can respond in quiet environment (See Annexure, Table 3).
- Results indicate 90% children not respond to speech sounds in noisy environment while 50% respond in quiet environment (See Annexure, Table 4).
- Results indicate that 50% children can localize environmental sound if it is loud enough, but 100% children can not localize sound if it is a low sound (See Annexure, Table 5).
- Results indicate that 90% children cannot differentiate in two environmental loud sounds while 100% can not differentiate when the sound is low or quite (See Annexure, Table 6).
DISCUSSION:
The present study aims studying “Parental awareness about Auditory Performance of their Hearing Impaired Children”. In this study fifty parents of hearing impaired children were asked about the auditory performance of their hearing impaired children. Age group of the children was between 3-9 years with severe to profound hearing loss. Children were from nursery to class one. Fifty percent were using analog body worn hearing aids while other 50% were using analog BTE hearing aids 70% of them were using hearing aids consistently while 30% were using in consistently. All of these children were either deaf or hard of hearing. It was found that mode of communication in these hearing impaired children was mostly Sign Language and Total Communication.
These children were consistently using amplification devices. Mostly parents were themselves using Sign Language and not emphasizing on responses to speech sound. When asked whether they themselves use different activities or games to improve their ability of identifying sound or localized sounds in the environment, 90% parents replied in negative this whole picture printed lack of awareness towards the importance of basic auditory skills needed at primary stage.
Special children were receiving speech therapy in their schools. Although no individual therapy was given to them they were receiving group therapy in their schools. There are many variables, which can effect on information and knowledge of the parents of these special children, but the areas from which the sample was collected and the minimum matric level of education was the factors, which were considered by the researcher in this process.
Results indicate that all four prerequisites auditory skills, meaning fullness of sound, identification of sound, discrimination of sound, localization of sound, which should be developed at primary school level were found delayed in these children as compare to other school age children. Parents are not fully aware about these skills of their special children. These children cannot identify or discriminate speech sounds unless the level of sound is very high.
Modler et-al (2006)[34], examines the receptive language skills of a group of school age children who were deaf or hard of hearing. This study postulated significant delay in comparison with normal hearing peers is consistent with other studies of school age.
Nancy (2006)[35] parental hierarchy for auditory training of hearing impaired children that must be followed by teachers working with these children or all multi-professional to bring positive results in their efforts.
1. Auditory Awareness and Perception –indicate the presence of sound.
2. Auditory Attention pay-inhibition attention to auditory information especially speech, for an extended time.
3. Distance Hearing-hear sounds from a distance.
4. Localization-Identify the source of a sound.
5. Discrimination-Differentiate and identify sounds and words that are acoustically similar of different.
6. Auditory Feedback and Monitoring-listen to auditory information and repeat and modify the speech production, if necessary, to match the auditory model.
7. Auditory Memory-Store and recall auditory stimuli.
8. Auditory Memory Span and Sequencing-Remember varying lengths of auditory.
9. Auditory Processing-Make cognitive judgments about auditory information.
10. Auditory Understanding-Comprehend auditory information in any situation.
While we still need to develop a better understanding of how deaf and hard of hearing children learn, we are cognizant of the fact that no single approach or strategy will provide the solution. We need to move away from standardized tests to assessments that will inform teachers, parents, and students through individually referenced performance measures. While there is little research to guide us, only when we have valid and reliable progress monitoring measures will we be able to identify instructional strategies and audiological, medical, and communication interventions that are effective or ineffective for a child.
The challenges in the application of progress monitoring tools with deaf and hard of hearing children are many (Luckner, 2005)[36]. Perhaps the most significant challenge is the variability within the population and the educational systems including communication systems and curricula. The second challenge is the lack of attention given to research and development efforts in the application of progress monitoring measures for use with children who are deaf or hard of hearing. Considerable time and talent have been dedicated to providing alternative or adaptive strategies in the administration of norm-referenced standardized achievement tests. While these are necessary and valued in the field of deaf education, increased attention must be given to providing teachers with technically sound tools germane to students with hearing loss that can be used as an integral component within the instructional process. A third challenge is the recognition that monitoring each student’s progress is crucial. Increasing the academic progress for each student with a hearing loss requires setting goals for academic achievement and finding the ways and means to achieve those goals.
RECOMMENDATIONS:
- Enriched auditory environment should be provided to the children of hearing impaired schools as well as home.
- Encourage using auditory verbal therapy approach.
- Emphasize on individual therapy approach.
- The auditory verbal therapist or school should arrange refresher courses for parents. Because to make parents and teacher aware the techniques that are helpful for child auditory development, perception, discrimination and comprehension.
SUMMARY AND FINAL THOUGHTS:
Early identification of auditory processing difficulties is warranted. In order to maximally assess children, a multidimensional team approach has been suggested for early analysis. The goal of this program should be to identify, assess and successfully intervene at the earliest possible time with maximal positive impact for the child.
ANNEXURE
Table 3: Response of the Child to Loud Environmental Sound
Description | Sound in Noise | Sound in Quiet | ||
| | Frequency | Percentage | Frequency | Percentage |
| No response | 40 | 80 | 5 | 10 |
| Minimal response | 10 | 20 | 10 | 20 |
| Moderate response | - | - | 25 | 50 |
| Significant response | - | - | 10 | 20 |
| Total | 50 | 100 | 50 | 100 |
Table 4: Response to Speech Sounds in the Environment
| Description | Sound in Noise | Sound in Quiet | ||
| | Frequency | Percentage | Frequency | Percentage |
| No response | 45 | 90 | 20 | 40 |
| Minimal response | 05 | 10 | 25 | 50 |
| Moderate response | - | - | 05 | 10 |
| Significant response | -- | - | - | - |
| Total | 50 | 100 | 50 | 100 |
Table 5: Localization of Source of Sound
| Description | Loud Environmental Sound | Low Environmental Sound | ||
| | Frequency | Percentage | Frequency | Percentage |
| No response | 15 | 30 | 50 | 100 |
| Minimal response | 25 | 50 | - | - |
| Moderate response | 10 | 20 | - | - |
| Significant response | - | - | - | - |
| Total | 50 | 100 | 50 | 100 |
Table 6: Differentiation of Sounds
| Description | Loud Environmental Sound | Quiet environmental Sound | ||
| | Frequency | Percentage | Frequency | Percentage |
| No response | 45 | 90 | 50 | 100 |
| Minimal response | 05 | 10 | - | - |
| Moderate response | - | - | - | - |
| Significant response | - | - | - | - |
| Total | 50 | 100 | 50 | 100 |
[1] EU Work Group (1996) EU Work Group on Genetics of Hearing Impairment. In: Martini A (ed) European Commission Directorate, Biomedical and Health Research Programme Hereditary Deafness, Epidemiology and Clinical Research (HEAR), Infoletter 2.
[2] Davidson J, Hyde ML, Alberti PW (1989) Epidemiologic patterns in childhood hearing loss: A review. Int J Ped Otorhinolaryngol 17: 239–266.
[3] Parving A & Christensen B (1993) Training and employment in hearing-impaired subjects at 20–35 years of age. Scand Audiol 22: 133–139.
[4] Paul PV & Quigley SP (1994) (eds) Language and deafness. Singular Publishing Group Inc., San Diego.
[5] Lucks Mendel L, Danhauer JL & Singh S (1999) Singular’s illustrated dictionary of audiology. Singular Publishing Group Inc., San Diego.
[6] Ibid
[7] Ingram D (1989) First language acquisition: Method, description, and explanation. Cambridge University Press, New York.
[8] Crystal D (1990) The Cambridge encyclopedia of language. Cambridge University Press, New York.
[9] Martin JAM (1982) Aetiological factors relating to childhood deafness in the European community. Audiol 21: 149–158.
[10] Morrison AW (1993) Acquired sensorineural deafness. In: Ballantyne J, Martin MC & Martin A (eds) Deafness. Whurr Publishers Ltd, London, p 181–213.
[11]Ibid
[12] Ibid
[13] Silman S & Silverman CA (1997) Auditory diagnosis. Principles and applications. Singular Publishing Group Inc, San Diego.
[14] ASHA (1998) Joint Committee of the American Speech-Language-Hearing Association and the Council on Education of the Deaf. Hearing Loss: Terminology and classification. Position statement & technical report. Asha 40 (Suppl 18): 22–23.
[15] WHO (1991) Grades of hearing impairment. Hearing Network News 1, September.
[16] Ibid
[17] Liu X & Xu L (1994) Nonsyndromic hearing loss. An analysis of audiograms. Ann Otol Rhinol Laryngol 103: 428–433.
[18] Parving A & Newton V (1995) Editorial Guidelines for description of inherited hearing loss. J Audiol Med 4: ii–v.
[19] Ibid
[20] Ibid
[21] Ibid
[22] Uimonen S, Mäki-Torkko E, Jounio-Ervasti K & Sorri M (1997) Hearing in 55 to 75 year old people in Northern Finland—a comparison of two classifications of hearing impairment. Acta Otolaryngol (Stockh) Suppl 529: 69–70.
[23] Duijvestijn JA, Anteunis LJC, Hendriks JJT & Manni JJ (1999) Definition of hearing impairment and its effect on prevalence figures: A survey among senior citizens. Acta Otolaryngol (Stockh) 119: 420–423.
[24] Uimonen S, Huttunen K, Jounio-Ervasti K & Sorri M (1999) Do we know the real need for hearing rehabilitation at the population level? Hearing impairments in the 5- to 75-year-old crosssectional Finnish population. Br J Audiol 33: 53–59.
[25] Arnold P (1998) Is there still a consensus on impairment, disability and handicap in audiology? Br J Audiol 32: 265–271.
[26] WHO (1980) International classification of impairments, disabilities and handicaps. World Health Organization, Geneva, Switzerland.
[27] Stephens D & Hétu R (1991) Impairment, disability and handicap in audiology: Towards a consensus. Audiol 30: 185–200.
[28] Ibid
[29] WHO (2001) International classification of functioning, disability and health. World Health Organization, Geneva, Switzerland.
[30]Flexer C. (1997). Facilitating Hearing and Listening in Children. 2nd ed. San Diego, CA: Singular Publishing Group, 1999:7.
[31]Hall, J.W. & Mueller, H.G. (1997). Audiologists Desk Reference. Volume 1: Diagnostic Audiology Principles, Procedures and Practices. San Diego: Singular Publishing Group Inc, 1997.
[32] Ibid
[33] Brassard, T. (1998). Auditory Processing. To Hear: To Listen and To Understand the Spoken Word. Canadian Hyperlexia Association.
[34]Modler et-al (2006) in Yesseldyke, J. and Algozzine, B. Teaching Students with Communication Disorders California: Crowin Press.
[35] Nancy Caleffe-Schenck, M.Ed., CED, CCC-A Certified Auditory Verbal Therapist (Feb 15, 2006) Auditory- Verbal Therapy: Developing Spoken Language Through Listening with Children Who are Deaf.
[36] Luckner, J. L., Sebald, A. M., Cooney, J., Young, J., III, & Muir, S. G. (2005). A review of evidence-based literacy research with students who are deaf or hard of hearing. Technical report from the National Center on Low-Incidence Disabilities. Greely: University of Northern Colorado.
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