Maximizing Outcomes for Children with Auditory Disorders: What are Children Hearing in the Classroom?

Editor’s Note: This is an edited transcript of the second webinar in a 3-part webinar series.  The webinar series is also available as a text course - access the text course here.

Dr. Jane Madell:  This is part two of our pediatric workshop entitled Maximizing Outcomes for Children with Auditory Disorders. In the first session, Dr. Flexer presented information about the auditory brain.  She underscored how critical hearing is in the development of the auditory brain.  In this session, I will discuss what children need to hear in the classroom to be successful.  In the next session, Dr. Gail Whitelaw will discuss an evidence-based approach to managing auditory processing disorders in children.  To earn CEUs for this material, you can register for all three sessions as a recorded course or as a text course.

Learning Objectives

At the completion of this course, you will be able to explain the critical nature of classroom listening, recognize classroom situations that interfere with listening and learning, and develop recommendations for improving classroom listening.

Assessing Auditory Functioning

Why is assessing auditory functioning important? Hearing is a complex function. It is not safe to assume that a child has normal hearing or normal speech perception. A child may respond to some sounds but not hear other sounds. If they are missing critical information it will interfere with learning. A child needs to be able to understand speech in both quiet and in noise. A child may be fine when it is quiet, but when they are at a distance from the person who is talking or when there is competing noise, this child may have problems.

A child may have an auditory processing disorder, which Dr. Gail Whitelaw will talk about in part three of this series. Children may have auditory attention problems, which means they may have difficulty paying attention to auditory information. They may be fine if they have a book or manipulatives in front of them, but if they have to get everything in auditory mode only, they may struggle.

We also have children who have sound sensitivities. These would be kids who are having problems attending to sound that is comfortably loud for the rest of us, but to them, it is too loud. If you can imagine spending your life listening to a world that is making you uncomfortable, you can understand why it could be a significant problem for a child to have sound sensitivities.

What Kids Need to Hear to be Successful

What do kids need to be able to hear in order to succeed? Infants and young children need an abundance language stimulation. The more they hear, the more they know. The amount of language to which a child is exposed is very critical. We know from the work of Hart & Risley (1975) that the more children are exposed to language, both the higher their vocabulary and the higher their IQ.

Children need to be able to hear well enough to pick up incidental conversation around them, not just what is spoken to them directly. About 90% of what kids learn is through incidental learning. Children with hearing loss may be able to hear well when you are standing in front of them, but they will not hear the conversation several feet away. In school, a child needs to be able to hear the teacher and their peers when they comment on classroom discussion, and they need to be able to hear on the playground and in the lunch room. Even though those may not be academic situations, they are still critical social situations. They need to hear normal and soft conversation in quiet and normal and soft conversation in competing noise.

Hearing – Listening – Understanding

There are inherent differences between hearing and listening and understanding. Hearing means that you are aware of the presence of sound. Listening is an active activity where you have to put forth some work to register the information. Understanding in the next step. While you may be hearing and listening, you may not understand the message. In order to understand, you have to have a sufficient language and knowledge foundation to be able to follow what is said. Understanding is our goal.

Normal Hearing

What is normal hearing? Normal hearing requires normal hearing thresholds throughout the frequency range. It is not okay to hear well in the low and mid frequencies and have a hearing loss in the high frequencies. That is not normal hearing, and I can assure you it will interfere with learning.

Speech Perception

Children also need normal speech perception. Speech perception for typically-developing children is 90-100% in all quiet and noise conditions. Excellent speech perception is 90-100%, good is 80-89% and fair is 70-79%. Anything less than 70% is poor. I always say, is it good enough for a math test? If it is not good enough for a math test, it is not good enough on a speech perception test.

Hearing in Noise

In addition to measuring speech perception, we need to know how children are hearing in noise, and we need to know if they are able to process auditory information. It is also important that whether or not they have middle ear disease. Some kids have a hearing loss related to middle ear disease and other kids do not. If you have a hearing loss from middle ear disease, it is likely to last for about six weeks. If a kid gets three ear infections a year,  that means she could have 18 weeks when hearing is compromised in the classroom.

Factors Affecting a Child’s Auditory Learning

The first factor that affects a child's auditory learning is obviously hearing.   How much auditory deprivation have they had? If they have had hearing loss or a middle ear disease or auditory processing disorders, they're going to have a period of not hearing and they're going to have reduced auditory exposure.

Children also need quality, constant language modeling. You could have the best possible hearing and technology, but if people are not talking to you, you will not learn. 

It is important to control the auditory environment. Children will not hear well if it is noisy, if there is reverberation, or if they are far from the person who is talking, unless we have the proper technology.

Hearing for Language Learning

Language is learned by listening. If kids have hearing loss and wear hearing aids only four hours a day, it will take them six years to hear what typical hearing children hear in one year. That is such a critical statement. It is not okay for kids to wear their hearing aids only part of the day or to take them off when they return from school. They need to have them on absolutely every waking hour or they will not learn and develop on the same track as their peers.

Classrooms are noisy environments; we know that. But academics rely on the child hearing what is said by the teacher and by the peers. If auditory functioning is not adequate, language learning, classroom learning and social skills will be limited because social skills are dependent on language skills. In the early years through about second grade, kids who have a language delay still manage to play with their peers, but by the time they get to the end of second grade, as language becomes more complex, it becomes much more difficult for them to continue to socialize. That is something we need to work on.

Because hearing loss is described by degree, it is important to recognize that not every child with a hearing loss or another auditory disorder is the same. If a child responds to sound, it does not mean that their hearing is normal. Some children, as said before, have good low- and mid-frequency hearing, but if they have a high-frequency hearing loss, they are going to be missing important  high frequency information about pluralization, possession and other significant grammatical markers.

A child may hear well in quiet but not hear well in competing noise. Any child who has problems with speech, language or learning needs a complete hearing evaluation, not a screening. We need to understand how they are hearing in a variety of different situations, including how their speech perception is at normal and soft conversational levels in quiet and in noise.

Hearing aids and cochlear implants are without a doubt wonderful devices. They make major improvements in what a child can hear, but they are not a cure for hearing loss. Children who have a hearing loss are still listening through a damaged auditory system. If you make hearing aids too loud, they may add distortion, meaning that the child will have difficulty hearing. Even though hearing aids and cochlear implants work well, kids will still have problems. The more severe the hearing loss or auditory processing problem, the more we can expect a child to have difficulty functioning.

Other Disorders Impacting Auditory Function

Other auditory problems exist that make learning difficult.  Auditory processing disorder is the inability or reduced ability to understand speech when the signal is degraded.  As with hearing loss, APD comes in degrees. Sometimes this disorder for children is severe, even when the hearing is normal.

Kids who have auditory attention disorders have a very hard time in the classroom. They have difficulty paying attention and understanding when information is presented in the auditory modality. The more visual cues they can get, the more that they can get from a textbook, the easier life will be for them. Kids with sound sensitivities may just have trouble paying attention because the world is too loud for them. We need to be aware of that and do everything we can to keep the classroom comfortable.

Kids with learning disabilities may also have difficulty hearing in the classroom. It may or may not be related to hearing or auditory processing, but these children needs the same kinds of accommodations of slowing down the classroom activity and making access to sound a little easier.

Learning Difficulties Associated with Audition

Children with auditory problems may have inconsistent responses to sound, and they may have difficulties with response timing. If you can give them another second or half a minute, whatever it takes, and they may be able to answer you, but they cannot respond quickly because it takes them a longer to process the information. As classroom discussion proceeds, they are left behind.

Children who have a short attention span for auditory stimuli and can only listen to audition for a short period of time will have problems learning. Kids with auditory problems may frequently ask for repetition, sometimes because they did not hear, do not understand it, or because they need longer to process it.  If they ask for repetition, they are going to hear it again, and during that time, they can probably figure it out. Children with any type of auditory disorder benefit from listening breaks – times during the day when listening is not critical. This will enable them to get back on track and attend better after the break.

Kids with auditory issues may have difficulty in phonics, remembering information that they learned auditorily, or knowing where the sound is coming from. It is helpful if the teacher calls out the child's name if a child is going to answer a question so that the child with the auditory disorder can know who will be speaking and direct their attention in that direction.

Some children have hearing loss in only one ear, and many people seem to think that it is not an issue, but it is. Bess, Klee and Culbertson (1986) tested children in school and discovered that one-third of the kids who had a hearing loss in one ear had to repeat a grade by third grade. Two years are critical. You need two ears to hear in noise, you need two ears to hear at a distance, and you need two ears to know from where sound is originating.

If a child does not hear well, their language is ultimately degraded, and consequently, their literacy skills are degraded, because literacy depends on language. Language also relies on phonics; kids with auditory disorders may have significant problems with phonics. Social skills may start to decline if language gets delayed because they are unable to keep up with the kids around them.

Monitoring Hearing

What can we do to monitor hearing so that we know that the children with whom we are working, with a variety of auditory disorders, are managing in a classroom setting? We need to be sure that classroom listening is enhanced. The classroom is an auditory-verbal environment. Children need to hear and attend to the teacher and to others around them in order to learn.

Speech perception is basic to learning. We need to know what kids are hearing and what kind of speech perception they have. Classrooms have poor acoustics because there are windows, doors, hard floors, ceilings and walls; all of those together cause problems. In addition, hearing loss or an auditory processing disorder is an acoustic filter in its own right, so even though we may have done everything we can do environmentally, the hearing loss is adding to the problem.

Kids Will Not Tell You When They Cannot Hear

As much as we would like to believe that kids will report when they cannot hear, this usually does not happen.  First of all, auditory disorders affect what they hear, so they do not even know that they missed something to report it.

We would like to believe that kids will advocate for themselves, but especially as they get older, they do not want to call attention to themselves, and they are not likely to ask for help. Classroom teachers need to be alert. You need to keep an eye on your kids with auditory disorders and see if they seem to be paying attention. If their attention is wandering, chances are it is because they are not following along.

They need to be hearing what other kids are saying. I did a school visit after the World Series in which the Minnesota Twins were playing. The teacher asked the class why the team was called the Minnesota Twins. The kids answered all kinds of things, and the teacher was not repeating any of their answers, and there was no pass around microphone in the classroom. I was very proud of this third-grade hearing impaired student who, after the discussion finished, raised his hand and said, "What was the right answer to the question?" He had missed the whole discussion.

Listening is Exhausting

It is important to recognize that listening is exhausting. Even when all the technology is working, a child with a hearing loss or an auditory processing disorder has to work much harder in order to learn. During the school day, it is critical that we give them some breaks so that they can recharge their intellectual batteries. If it appears that they are tired or attention is wandering, someone needs to address that.  They need to be seated strategically so that they can both hear the teacher and see the teacher in the classroom. If the teacher turns around to write on the blackboard, the child's ability to use lip reading is lost. One strategy may be to write on the blackboard and then turn around and face the classroom.

Strategic seating is important. The best possible place for most kids is to one side, about a third of the way back from the front of the room. That gives them the ability to turn around and look at the classroom and see what is happening. If one ear is better than the other, strategically seat them with their better ear facing the classroom.

Children with hearing loss or an auditory processing disorder may need help listening in a lot of other situations, not just the standard teacher-in-front-of-the-classroom. They need to be able to hear computers or video or if they are watching a film. Captions should be used on all film given to any child with an auditory disorder; and are likely helpful for everyone in the classroom. There needs to be a way to plug the FM system into computers and other devices so that the kids can hear. They also need to be able to hear in the lunchroom and the playground.  Anything we can do to make those situations easier for kids is something we should do.

Who is Monitoring Performance?

In order to help kids succeed in the classroom, clinicians and teachers have jobs to do. We need to do a daily check of the equipment. You cannot assume that the equipment is working just because the child puts it on. We need to check it every day to make sure that the child is hearing and understanding.

We need to monitor their auditory learning. How do we know that the child is getting what is happening in the classroom on a regular basis? Are they getting it auditorily?  Are they looking at the book or at what other kids are writing down?

We need to know their spoken language comprehension. We need to know what their phonologic awareness skills are, because those are critical for learning to read. We need to analyze a receptive language sample so we can make an estimate about how much of the classroom activities the child can access. We need to look at spoken language processing. How well do they follow and participate in discussion? What is their written and spoken language like?

Someone has to be assigned to check the hearing aid and FM.  That should happen twice a day for kids through grade two; by third grade, hopefully the kids can participate, and we can do once, first thing in the morning.  In many schools, the classroom teacher takes responsibility for this. If not, is there a speech pathologist, a teacher of the deaf, an educational audiologist, the nurse or someone in the special education office who can take responsibility?

Parents have a responsibility, too. They need to be sure that the child comes to school with working equipment in the morning with sufficient batteries and backups as well.  They are not going to be in school, and they are not going to be there when the FM gets checked, so someone at school needs to be responsible.

What is the role of the educational audiologist? Hopefully the school has an educational audiologist available for consulting at the very least. If there is an educational audiologist in the school, they can help the assigned party learn how to do the listening check. If there is not an educational audiologist in the school, then an audiologist from the community needs to be involved in consulting and helping to assure that everyone in the school understands the issues.

Listening Checks

When doing a daily listening check in school, have the child stand approximately three to six feet away with his back turned away from the tester. The tester can present the Ling sounds - ah, ee, oo, sh, s, m - at a normal conversational level, and have the child repeat them. You do not want the child to be able to predict what you are saying so present them in random order. After that, you can use familiar words - shoe, hot, plane, foot, sky, books, - some with sibilants or fricatives in them so we can be sure the child is hearing high frequencies. We can try sentences and questions.  For example, “How many people are wearing red shirts today?”  This way we can know the child both hears and understands.

It is useful if we can test in quiet and in noise. It is important that the material be unpredictable so the child cannot anticipate what it is we are asking every day.  Test with the FM system always.

Keep notes of what the child is hearing, and even more importantly, what the child is missing.  The audiologist can use that information to modify the technology so the child will hear better, and the speech therapist/auditory-verbal therapist and teacher of the deaf will be able to use that information to plan therapy goals.

Listening in Noise

Let's talk about listening in noise. Classroom acoustics are a big issue. Some of these thing we have control over and some of them we do not. If a classroom has one 40-watt bulb, would anybody consider that appropriate lighting?  Of course not.  So at construction time, they plan for that so that the lighting will be appropriate.  Acoustic treatment often gets ignored in classrooms. In fact, it accounts for only one to five percent of the construction budget, depending on a variety of things. At this time, only 10 to 30% of classrooms meet the current standards for listening.

In one national survey, 30% of classrooms were judged too noisy by educators for typical-hearing students (Anderson, 2001). For a child with an auditory disorder, imagine what that means. The primary problem was hearing ventilation and air-conditioning systems and classroom reverberation. It is important to know that students under the age of 13 are the ones who are most challenged by noise, so until a child is in seventh grade, they are going to be having trouble managing hearing if the classroom is noisy. Noise is almost always underestimated by teachers because, as adults, they are capable of handling noise, and they do not recognize how difficult it is to hear in many situations.

Because teachers talk loudly in order to talk over the noise, they are at a 20% greater risk than other workers of damaging their voices. The average teacher takes one sick day a year due to voice problems. When a teacher raises her voice, vowels get louder but consonants stay weak. You cannot yell "s" or "f." So while you think you are talking louder, you may get the kids’ attention, but they are missing a significant amount of information.

Again, strategic seating is very important. The teacher's voice or the peer’s voice needs to be at least 15 dB louder than the noise.  This gives us great support for the importance of using an FM system.

English-as-a-Second-Language (ESL) students also have a significant problem hearing in a situation that is noisy. Students who are learning in a non-native language experience exactly the same effects as a child with a 25-40 dB hearing loss. It is not a minor problem.

Classroom learning can be affected by rate - how fast is the material coming? The majority of adults speak at about 200 words a minute, and children learn best at 120 words a minute. Slowing down would be a big advantage. It can be difficult to learn that skill as a speaker, but it is critical that we slow down.

Children educated in noisy classrooms tend to give up first. Research conducted with subways and freeways as noise sources found that kids who were on the side of the school closest to these noise sources had a one-year drop in grade equivalent achievement scores.  In two different studies, the kids had noted difficulty in the areas requiring language, and literacy.

The Role of FM Systems

Children do not habituate to noise. They have trouble hearing. So should all classrooms have an FM system? Obviously, my answer to that is yes, because an FM system will make a significant difference over any modifications we make to heating, ventilation and air-conditioning systems or strategic seating. If the child does not have sufficient accommodations, (e.g., controlling the noise environmentally and controlling the seating) and an FM system is not accessible, their performance is going to decrease over time. You may not see it in the first week, but after a few months, this child will be struggling.

The way to solve the problem of hearing in the classroom, first and foremost, to use an FM system, which will reduce the effect of both distance and noise. Keep in mind it will not eliminate them completely. The talker needs to use a microphone, and placement is important. Ideally, the best thing you can do is use a boom mic, because then the microphone is right in front of your mouth all the time. If you bend down, if you look up, if you turn right or left, the microphone is in the same place related to your mouth. The problem is that most people do not use a boom mic, and that is unfortunate. If you clip a mic to your shirt, you significantly reduce the amount of sound when you turn your head from left to right, which happens all throughout the day.

The microphone should be no more than 6 inches from the speakers mouth. When I go into a classroom, I cannot tell you how often I find the teacher's microphone too low on her shirt or sometimes even on her waist. Think about how much sound is lost by having the signal go from your mouth to something on your waist. The microphone should be no farther from your mouth than the width of your hand when you open your fingers wide.

Receivers

There are a number of possibilities for what a child can use as a receiver. They can have one that is attached to their hearing aid or their cochlear implant with an adapter we call a boot. If the child has an auditory processing disorder or a unilateral hearing loss, they can wear a small receiver on the good ear that looks like a hearing aid. Those are the best options because the sound is going directly to them.

The next option is having a loud speaker on the child's desk, but if the child moves around the room, she has to carry the speaker with her.  Another variation on this is a free-standing loudspeaker in the classroom, which is a classroom FM system. This kind of FM system will improve the signal for all students by decreasing the effect of distance and noise and decreasing the echo from sound in the room. It also decreases the stress of listening, because the child is hearing things a little more clearly and louder. Remember that they only hear what is going into the microphone. If the microphone is turned off or if other children in the room are not using it, the intended child is going to have trouble managing.

Sound field listening systems work well for children with normal hearing. They improve listening in the classroom and improve reading and language. But children with auditory processing disorder or hearing loss need a personal, wearable FM system in order to hear well. Sound field systems are not good substitutes for merely any child with an auditory disorder.

In 2012, Jace Wolfe and colleagues published research showing that as the noise level increased for a group of children with hearing loss, scores were consistently better across the board with a personal FM system AND a dynamic classroom system used in conjunction. A study by Schafer & Kleineck (2009) clearly points out the effect different FM systems have on a child's cochlear implant performance, but it can likely be assumed that the results are similar with hearing aids. Personal FM systems improved speech perception by 38%. A desktop system improves speech perception by 17%. Sound field systems improved speech perception by 3.5%. There is absolutely no doubt that a sound field system will not work for a child with any auditory disorder. They must have personal FM.

For children to hear other children in the classroom, ideally, there should be a second mic called a pass mic, which they kids can take turns speaking into so that the child with the auditory disorders will hear everything through their receiver. If this is not an option, the teacher can repeat what is said by every child in the classroom.

Monitoring the FM System

It is important to know that FM systems are electric, and they break. If we want to assure that they are working we need to monitor them. Who is going to charge the system? Who will do the daily monitoring of listening? Who is going to be contacted if there is a problem? Is there an educational audiologist you can get in touch with? Who sends the equipment out for summer service? Who checks the batteries to make sure that they do not need to be replaced? If you send it out for summer service, you will know that they are in good shape.

Classroom Observation

We need to know who is conducting the classroom observation, how often it is conducted, and is the person who is conducting the classroom observation someone who knows about hearing loss and other auditory disorders? If not, they are going to miss a lot of things that are happening in the classroom.

What do you need to look for in a classroom to know that a child with an auditory disorder is functioning well? Is the child following what the teacher says or do they seem to be wandering? Can he follow directions without assistance or does he need to peek over his neighbor’s shoulder to look at what his neighbor is doing? Does she volunteer, and when she volunteers to answer a question, are the answers appropriate? Are they sufficiently complex, or are they very simple? Does the child with an auditory disorder attend to what the other children are saying? Can he hear them? Is she seated appropriately, and can she move her seat if she needs in order to follow discussion?

How does the child handle a communication breakdown? We know kids are not good at consistently saying, "I cannot hear you,” or, "My FM system is not working." Does the child appear tired at the end of the day? Is the child socializing with other kids in the classroom? Do they have contact with other people around them?

FM System

Is the teacher using the FM microphone? Is it turned on? I got a telephone call from a mom I work with last week saying it was the first day of school, the educational audiologist had not shown up yet, so she and the teacher were trying to figure out how to get the FM to work. The mother was very upset, and the child was upset.  She is in third grade.  She does not know how the teacher's mic works, and it is not her job to know how the teacher's mic works, but nobody else knew how the teacher's mic worked.  The audiologist was coming two days later; that is a problem.

Is there a pass mic in the classroom, and if so, does everyone know how to use it? Do the students wait for the mic to speak? I like the concept of the American Indian talking stick. You can only talk when you are holding the stick. If you do not have the stick, it is not your turn to talk. It helps kids wait for their turn, and it helps everybody know who is speaking. The pass mic can work as a talking stick, also. If there is no pass mic, the teacher has to repeat all the comments of other students. Everything any child says in the classroom is important. There is nothing more frustrating for a person with hearing loss than to hear somebody say, "It does not matter. Don’t worry about it."

Is the room quiet? Is the air conditioner working? Do all students know you cannot get up and go sharpen a pencil in the middle of instruction? Does the student need extended test time? Do they have trouble completing things in one test session? 

Child’s Standing in the Classroom

It is important to know where the student stands academically in the classroom. Is the student on par with the other kids, or are they far below? Are the teacher's goals for the student with hearing loss different than their goals for other children? I got a telephone call from a mom who said that the teacher assigned the students to go into groups, and she said to the hearing-impaired child, "I do not know how to deal with you, so you are going to be in a group by yourself.  I just do not know how you will work with other kids." This was a child who could very easily have worked with other kids. Teachers need to understand children with hearing loss. Their goals for the child with a hearing loss or other auditory disorder have to be the same as their goals for the other children in the classroom, because kids achieve what they are expected to achieve.

Observe Speech and Language and Teacher of the Deaf Services

When you are doing a school observation, we want to observe speech and language services. Are they appropriate? Does the speech-language pathologist understand hearing loss? Are they focusing on audition, because kids need to learn using audition. Is the teacher of the deaf doing preview and review of vocabulary? That is one of the most valuable services for a child, and I strongly recommend it for almost every child with hearing loss. When you preview the words that are coming up in science and math before the concepts are formally taught, the child is prepared to learn those with the rest of the class and has the vocabulary to start.  Then, review it to make sure the child got the concept after it has been taught in class.

It is important that the special education staff understand what was found during the classroom observation and what we think needs to change. Teachers, clinicians and other classroom staff need to do daily listening checks, monitor auditory learning, monitor spoken language comprehension, monitor phonologic skills, and monitor receptive language. Every three years is not enough to get a measure of what a child can do and understand.  We need to modify the classroom's functioning on a regular basis.

Indicators that may be Compromising a Student’s Performance

Any indication a hearing or another auditory disorder may be compromising a student's performance is important. If a child gives inappropriate answers to simple questions, they may not understand them. If they frequently ask for repetition, then there is a problem getting the information. As I said earlier, it may be they are not hearing, it may be language or maybe that they need additional time to think about it.

If they have poor attention, we need to check that they are hearing what is being said. Do they appear to be isolated from their peers? Are they easily fatigued when they listen? Do they go home exhausted and unable to pay attention? Do they have a low tolerance for frustration? What are the child's reading and language skills? What is their written language like? Is the grammar appropriate? We need to be looking at all those things so we can figure out what we need to do to manage and monitor services for this child.

Classroom Accommodations

Classroom accommodations can be viewed as anything to help the child success.  For a child with an auditory disorder to learn and master content, they need to understand the teacher and their peers. They need to express their thoughts and ideas, both spoken and in writing. They need to be able to ask for clarification when information is not clear to them, and they need to be able to interact with classmates.

Factors that Impact Access in the Integrated Classroom

Factors that we know impact access in an integrated classroom are the rate and pace of instruction, the rigor of the instruction, the expectations for the child with an auditory disorder, the ability to use incidental learning from others around them, and the complexity of the language instruction. Is the language instruction at this child's language level or is it higher than this child can manage?

When selecting a classroom, ideally we would select one situated away from the playground or a busy street, away from bathrooms, enclosed walls, and with carpeting in noisy places, such as under blocks or building manipulatives in younger grades. Acoustic tiling should be in any place we can put it.

Acoustic Modifications

Some modifications to the classroom are easy, and some are more complex.  First, keep the doors and windows closed whenever possible so you do not introduce outside noise from the hallway. Add tennis balls, felt tips or footies on the chairs and table legs so you do not create excess noise when moving them. Area rugs can be placed in noisy centers. We have some control of those things; we do not have control over the heating, air-conditioning and ventilating system, but we do need to be sure that we have done anything we can do to get it cleaned and quieted.

Auditory visual equipment like computers all need to be monitored, and we need to be sure that kids have a way of plugging their FM into them so that they can learn and hear well.

What does the School Staff Need to Know?

In the school setting, it is not enough to know that there is a child in a certain class who has an auditory disorder. The student's level of confidence in listening and conversational skills is very critical. The teacher needs to know what to expect. Can this child follow third-grade material when they are in the third grade, or is this child functioning at a lower level? The teachers need to know the developmental hierarchy for repairing communication breakdowns; the speech pathologist, teacher of the deaf, or auditory-verbal therapist in the school should be able to help with that.

Teachers need to know suggestions for reinforcing skills in different environments. We cannot let the child go to the playground or go into the lunchroom and without know whether the child can hear in those situations. Somebody needs to be responsible for teaching self-advocacy skills so that kids can learn to ask for assistance when they are struggling.

A teacher's style can also have an effect on a child’s learning. Call the child by their name and make sure they are listening before we impart new information or ask questions. At many times during the day, we want to check that the child understands what has been going on. Repeat what other children say if you do not have a pass mic, and even if you do not have a pass mic, use the concept of the talking stick. Arrange for listening breaks. Everybody in the classroom would benefit from listening breaks during the day when you do not have to listen to do whatever it is you have to do. For a child with an auditory disorder, these breaks are critical.

All assignments have to be written on the board or in a handout; it is not reasonable to say out loud, "I want you to do math problems number 7, 9, 11 and 26 from chapter three." If a child misunderstands that, they are not going to get the homework.  Those things have to be written down so that the child has the ability to know exactly what is expected of them. We discussed pre- and post-teaching, which is another strategy we can use here, with cooperation from the special education or auditory impairment teacher if needed.  Lastly, teachers need to keep the classroom quiet.

When we do evaluations, we need to look at the breakdown of each component. What are the sub-test scores for standardized testing? You may get 92% on one kind of learning and 32% on the other. When you add them up, the child still is coming up as an average student, but that 32% score is going to drag them down. We absolutely need to know areas of weakness, and we need to monitor their functioning in all academic areas, while providing assistance so we can build skills in their weak areas.

Suggestions for the Teacher

The first suggestion is strategic seating. Again, face the student with the light on the teacher's face, not with the light shining in the student's eyes. Speak naturally; do not exaggerate what you are saying because it is very hard to lip read exaggerated speech. Provide visual access to information, outlines of the course if possible, and written assignments. When pointing to charts or handouts or writing on the board, pause to allow the student to look at the material, and then resume speaking. Monitor what the child is hearing in the classroom, and repeat or rephrase if there are questions and comments.

Sometimes if the child asks for repetition, it means they did not hear; sometimes it means they did not understand. It is important to know which of those is the case so you know how to solve the communication breakdown. Provide listening breaks, but hold the child with hearing loss or any auditory disorder to the same standard you do with other kids in the classroom. These kids are mainstreamed because we want them to learn with their peers.

For some children, it may be useful to assign a buddy who is sitting at their table and can remind them what page they need to be on if something is called out. The FM system needs to be used for all academic work. Try this to remember what has to happen by using the acronym "SPEECH."

S - state the topic to be discussed;

P - pace the discussion at a moderate speed with occasional pauses for comprehension;

E - enunciate clearly without exaggerating lip movements;

E - enthusiastically communicate using body language and hand jesters;

CH - check for comprehension before changing topics.

The appropriate mic placement for an FM system is six to eight inches away from the mouth, not over to the side. Turn the mic on when you are talking to the child who needs it, but if you are walking around the room and having a conversation with another child, mute the microphone. I can tell you that kids with auditory disorders sometimes become very popular because they hear things that they are not supposed to hear; it is not unheard of that a teacher forgets to turn off the microphone while having a conversation with teachers in the hallway or going to the bathroom. You only have to do that once before you do not make that mistake again.

Check with the child periodically. Ask them questions about what is happening, and develop a system where the child can report problems without having to raise their hand to say, "My FM's not working.” You need a system where the child will not be calling attention to himself.

Access

Access builds the auditory brain. Can the child hear the teacher? Can they hear other students? Do they have the vocabulary to understand the classroom activities? Can they overhear so that they can take advantage of incidental learning? Can the child follow other students' comments? Is the technology working?

Unfortunately, in the last 40 years, the situation has not improved. More than 50% of technology is not working on any one day. Five studies from 1966 to 2011 showed the same thing. The most common problem is dead or weak batteries. This problem can be reduced by at least half if someone in the school is responsible for checking the technology daily.

Conclusion

Thank you for your interest in this course, and I hope you have found valuable concepts you can apply to children in the classroom.  The books Dr. Flexer and I have written are listed in the references. Both might be of interest to audiologists and auditory therapists learning about hearing loss.

Please take advantage of the other courses in this series by Dr. Flexer and Dr. Whitelaw.

References

Anderson, K. L. (2001). Voicing concern about noisy classrooms. Educational Leadership, 58(7), 77-79.

Bess, F., Klee, T., & Culbertson, J. L. (1986). Identification, assessment, and management of children with unilateral sensorineural hearing loss. Seminars in Hearing, 7(1), 43–50.

Hart, B., & Risley, T. R. (1975). Incidental teaching of language in the preschool. Journal of Applied Behavior Analysis, 8(4), 411-420.

Madell, J., & Flexer, C.  (2013). Pediatric audiology – diagnosis, technology and management, 2nd edition.  New York, NY: Thieme Medical Publishers.

Madell, J., & Flexer, C. (2011). Pediatric audiology casebook. New York, NY: Thieme Medical Publishers.

Schafer, E. C., & Kleineck, M. P. (2009). Improvements in speech recognition using cochlear implants and three types of FM systems: a meta-analytic approach. Journal of Educational Audiology, 15, 4-14.

Wolfe, J., Morais, M., Nuemann, S., Schafer, E. C., Mulder, H. E., Wells, N., et al. (2012). Evaluation of speech recognition with personal FM and classroom audio distribution systems. Journal of Educational Audiology, 19, 65-79.