Interview with Pamela Paskowitz and Ellen Hansen

Topic: Visit to Summit Speech School

Pamela Paskowitz



Ellen Hansen

Carolyn Smaka: This is Carolyn Smaka from AudiologyOnline, and today I'm at the Summit Speech School in New Providence, NJ, speaking with Pamela Paskowitz, Executive Director, and Ellen Hansen, Pediatric Audiologist.

Thanks for having me today. To get started, can you both tell me about your backgrounds?

PAMELA PASKOWITZ: I have a BA in Speech Pathology from Mt St. Agnes College, Baltimore, MD an M.E.D. (Master in Education of the Deaf) from Smith College, Northampton, MA and a PhD in Speech Pathology from Ohio University, Athens, OH.

I have been in education for 40 years, teaching students preschool through college who have had learning disabilities or who were deaf or hard of hearing. Most of my teaching was done in Baltimore where I was a classroom teacher, speech-language pathologist, and clinical supervisor in Loyola College's speech path program. I spent 12 years at the Clarke School for the Deaf in Northampton, MA. For the eight years prior to my coming to NJ, I was Director of School, Research & Related Services at Clarke. I have been Executive Director at Summit Speech School for six years and have seen tremendous change during that time both in curriculum and in the children's progress. Two of the most significant changes have been the revamping of our curriculum to one based on a Moog model and starting an audiology program with Ellen as our pediatric audiologist.

ELLEN HANSEN: I have over 32 years of experience working with infants and children. Prior to my current position as an educational audiologist and establishing the new Audiology Center at Summit Speech School, I worked as a clinical pediatric audiologist with Central Jersey Otolaryngology. I also started the Department of Audiology for Children's Specialized Hospital in Mountainside, N.J. My special area of expertise is working with developmentally challenged, difficult-to-test populations and typically developing children with hearing/speech/learning disorders. I have a Bachelor's Degree in Speech Pathology and a Master's Degree in Audiology. I also hold a Certificate of Clinical Competence in Audiology from the American Speech Language and Hearing Association, and I am a fellow in the American Academy of Audiology. I have served on numerous state committees for the education of children with hearing loss as well as newborn hearing screening programs. I've also lectured extensively in the areas of the identification and management of hearing loss in the pediatric population, and consulted with school districts throughout the state. In addition, I am an adjunct professor at Seton Hall University and Montclair State University.

SMAKA: Tell me about Summit Speech School.

PASKOWITZ: Summit Speech School was founded in 1967, and was the first private auditory/oral school in N.J. There are several programs here. Through our Parent Infant Program we see children from birth to age 3 with their families in their homes. We have an on-site Preschool Program for children ages 3 to 5. We have an Itinerant Teacher of the Deaf Program to support children who are mainstreamed. And we have an Audiology Center that services children birth though 21 and provides educational audiology services to school districts.

Our Parent Infant Program offers parents and families skills, support and confidence to help their child learn to listen and talk. As I mentioned, these individualized sessions are provided at home or in childcare settings. They are guided by certified Teachers of the Deaf and focus on auditory habilitation and speech/language development. Additionally, toddlers between the ages of 15 and 36 months are eligible to receive additional on-site services in our Sound Beginnings group program. Children work with our professionals while the parents participate in facilitated support and educational sessions. Our goal is to have children amplified early with appropriate intervention to train the brain to listen and the child to talk.

Our onsite preschool program uses intensive small group language/listening sessions alternating with larger group content-specific lessons. Our speech-language pathologists, classroom teachers and teaching assistants work as a team to track all aspects of the children's speech, language and auditory development. In addition to the audiology services that Ellen provides, we also have speech-language therapy, occupational therapy and physical therapy available.

Our Itinerant Teacher of the Deaf program provides services for children who are mainstreamed across N.J. We work collaboratively with schools and school districts to provide services tailored to each child's specific needs to maximize their academic experience. We can provide in-service sessions to district personnel on hearing loss, its relation to speech, language, academics and social skills and on equipment use. We can provide consultation to teachers, speech pathologists and CST members and we can work directly with the children anywhere from 1 to 5 hours per week. Ellen has also been providing educational audiology services for several districts, doing acoustic evaluations and checking and maintaining FM equipment.

Through our audiology center, Ellen can schedule hearing evaluations for community children and youth, birth through 21.

SMAKA: That's an impressive array of programs.

My first question to you both is, how have cochlear implants changed the education of children with hearing impairment?

PASKOWITZ: I have been in the field 40 years and it's miraculous what has happened in deaf education over that time. What we considered good speech, language and auditory skills for a child with hearing impairment even ten years ago, is no comparison to what we see today. If a child is identified and amplified appropriately early enough and receives appropriate auditory verbal early intervention we pretty much can expect normal speech and language development. Of course this is barring the cause of deafness and any other issues at hand. Audition tends to develop before speech and language;the listening skills of children with cochlear implants who are amplified early are excellent. The distance at which kids with cochlear implants can hear is also impressive. For children with more significant losses who wear hearing aids, that distance may be 3 feet, 6 feet or at most 12 feet. With cochlear implants we've found we can move 25 feet away from the children and they're still picking up auditory information. It's wonderful to have seen these changes over the years.

In our experience with toddlers and preschoolers, we notice that during the first year after implantation listening skills progress steadily. The second year after implantation can be striking. Something seems to 'click' during that second year and speech and language skills take off. For some children language skills develop slower than we would like during the first year. We wait and we're not quite sure the child will be successful with auditory/oral skills. Then something happens during the second year and skills develop beautifully. Of course this is not always the case. In the first year, we expect to see one or 1 ½, maybe even two years of progress in speech and language development. We're patient since we know children progress at different rates. During the second year, we must see 1 ½ to 2 years of progress or more in speech and language development if that child is to continue with auditory/oral speech and language. Language development is especially critical because the language gap has to close or be almost closed before age 5 or 6 at the latest. As magical as implants are they are not a "cure all." Some children need more than the implant can provide. Their brains have difficulty processing language and auditory information. Some children with implants do need sign support. We then make referrals to a more appropriate educational placement.

SMAKA: Do you have many children here that use bilateral cochlear implants?

PASKOWITZ: Yes. I've been here six years and we didn't have children using two implants when I first started. I think this was because of reimbursement;insurance was not covering a second implant. Now, children with single implants are going back for the second. And some of our younger children are getting a second implant within a year of the first. We're seeing more sequential than simultaneous implantation.

With one cochlear implant, children can certainly do very well. However, the fact that a child does very well may be a detriment to that child when she/he is placed in a mainstreamed classroom. With a cochlear implant, that child still has a mild hearing loss in the ear with the implant and usually a severe to profound hearing loss in the other ear. Therefore the child still presents with a significant unilateral hearing loss. We know from the literature as well as from experience that children with unilateral losses may indeed have academic issues. The fact that the child with an implant still has a hearing loss may be totally ignored once the child is in a mainstream classroom. Team members often say, "This child is doing so well she doesn't need any services." The child then does not receive necessary accommodations for the hearing loss.

HANSEN: As Pam mentioned, a child who is bimodal functions with a mild hearing loss in the implanted ear and a significant loss in the other ear while listening with two different types of technology. We have a 3 ½ year old child here who explained this beautifully. He wears an implant in one ear and a hearing aid in the other. Just recently he pointed to his ear with the hearing aid and told us, "I don't really like listening in this ear. I like my implant much better." Even at a very young age, he could tell the difference between hearing with his implant and hearing with his hearing aid.

So we really need to drive home the point that a child using one cochlear implant still has an educationally significant hearing loss.

To help parents and therapists understand this, we will simulate a hearing loss. We have computer programs that help us do this. We know the issues that go along with a unilateral hearing loss: difficulty hearing in noise, difficulty localizing, difficulty hearing at a distance, especially when signals come from the direction of the poorer ear, and fatigue from all of the extra effort that goes into listening, just to name a few.

Children with cochlear implants still may need acoustic modifications in the classroom, an FM system, and other assistance to support them in school. They are at a disadvantage in school, even when they appear to be doing well.

SMAKA: In your experience, what helps parents with the decision of whether or not to seek an implant for their child, and whether or not to opt for a second implant?

PASKOWITZ: There is still a fear factor in both cases: "Should we or shouldn't we?" In many cases, parents of young children aren't aware of other children or families who have gone through the process of having an implant.

HANSEN: Parents learn from other parents when they come to our toddler group.
Parents have said that they made the decision to consider an implant when they saw how other children were progressing. When they had the opportunity to talk with other parents and share experiences, and when they heard the speech and language of many of the children who have implants, it definitely made their decision easier. A lot of the fear is of the surgery itself. Speaking with other parents helped to calm their fear.

SMAKA: Do you see parents come in with misinformation about implants?

HANSEN: Yes, we do. If the audiologist is not one who typically works with children with implants, misinformation can occur.

SMAKA: What are some of the challenges you see with children who wear hearing aids?

HANSEN: We find that often hearing aids are fit conservatively and functional benefit is not assessed. Consequently the child is not receiving full access to speech or the full benefit of his/her hearing aids.

This goes back to the importance of measuring the functional benefit of the amplification system, whether it's hearing aids or a cochlear implant. We find that the cochlear implant centers routinely assess functional benefit of implants. With hearing aids, however, this is not usually the case. Real ear assessment is not sufficient. It is critical to determine a child's access to speech wearing his/her hearing aid. If a child has a severe to profound hearing loss and aided benefit with hearing aids is still in the moderate to severe range, that child is not going to have full access to the speech spectrum with hearing aids alone. You will not know this unless you measure it. These are the cases where the family needs to think about the potential of a cochlear implant, and to work with an audiologist who has experience transitioning children from hearing aids to cochlear implants.

SMAKA: Ellen, when you refer to measuring functional benefit, what specific assessments are you referring to?

HANSEN: I'm referring to behavioral testing with speech stimuli. The assessment used will depend on the age of the child. For very young children we will often use the Ling Six Sounds Test. Obviously, if the child is very young they may not be able to identify the Ling sounds by producing them, so we would measure detection. Since the Ling sounds span the speech spectrum, this test provides us with an idea as to the child's access to the speech spectrum.

When the child is a little bit older we would still use the Ling Sounds. They give us a functional measurement of how well the child is hearing in that portion of the speech spectrum.

We use word recognition tests that are age appropriate, whether it's the NU-CHIPS, the WIPI, NU-6 or others. It's helpful to involve the child's speech-language pathologist or teacher to find out what vocabulary is familiar to the child.

It is important to assess word recognition ability at conversational and soft speech levels. It's also important to test in background noise, using either a +5 or +10 dB signal-to-noise ratio.

When testing functional benefit, it's helpful to look at the errors. Document the child's substitutions and omissions and see if there is a pattern. I will look at the frequency range where the errors fall. If a child is not hearing a sound correctly she/he will not produce it correctly. Speech perception will be reflected in speech production. This type of information can be helpful for decisions about amplification such as hearing aid re-programming and cochlear implant mapping, as well as for speech-language therapy, etc.

In addition to auditory only tasks, I may present words that were missed during word recognition tasks with speech reading. A significant improvement in the word recognition score supports the need for visual cues in the academic setting, especially in the presence of noise.

My intention with testing functional benefit is to describe typical situations that that child might encounter, determine how the child performs in those situations, and then determine what recommendations are in order to promote the best possible performance.

SMAKA: Have cochlear implants changed the way that Teachers of the Deaf work?

PASKOWITZ: Absolutely. Teachers of the Deaf more now than ever before have to have a background in speech perception, audition, language development and speech development as well as in FM systems, hearing aids, and cochlear implants. If they do not have a strong background in these areas, it is going to be to the detriment of the children. Teachers of the Deaf need to know as much about language and audition as they need to know about academic subjects. If a child is not doing well in a particular academic subject, they need to ask, "What is the child not hearing? What language structures are missing? How do I improve that to improve the child's performance in the academic subject?"

Those of us that were trained years ago, before cochlear implants were available, will not be as effective in our field if we do not keep up in these areas.

SMAKA: Will there still be a need for Teachers of the Deaf in the future, since so many children with amplification perform so well now?

PASKOWITZ: There will always be a need for Teachers of the Deaf because even with cochlear implants, the brain doesn't immediately learn to listen. It still needs to be taught how to listen.

The population with which the teachers work will be younger and younger. You may not see the teachers working with late elementary, middle school or high school kids but I think there will always be a need in the infant population through the early childhood years. Who knows what amplification of the future will be like? But right now I think the assumption is that in our lifetime there will be a need for Teachers of the Deaf.

HANSEN: In our program, Teachers of the Deaf - whether they are in our preschool program, parent/infant program, or itinerant program - learn about implants.

Our technical coordinator, Susan Chorost, is very well versed in cochlear implants. When someone is new on staff they spend hours with Sue learning how cochlear implants work, about FM systems, and how to troubleshoot. Our Teachers of the Deaf have a good foundation in amplification and technology. They can always get on the phone and call us if they are out working at a school or with a family and have problems.

We have also received calls from Teachers of the Deaf who are not affiliated with our school but who need guidance and direction with cochlear implants or FM systems because they have had little training or experience with audiological equipment. It's a whole different world out there from when they were trained. We're happy to help.

PASKOWITZ: We also have the benefit of having a good relationship with equipment manufacturers. When a new FM system, hearing aid, or implant is introduced, we can have educational workshops here for our staff. We've opened the workshops up to audiologists in the community as well, because we know there is a need to stay up to date with the technology.

SMAKA: Do the children that you have here currently have all degrees of hearing loss?

HANSEN: Yes. From mild to profound, and some children have unilateral hearing loss.

SMAKA: What is your policy on sign language?

PASKOWITZ: We are an auditory oral school and we try to follow AV principles. However, we realize that if we have a child here for 1 to 1 ½ years, who is getting 2 to
2 ½ hours of language a day either individually or in a group no larger than three, plus one half hour of speech every day and that child is not making 1 ½ to 2 years progress in speech and language per year, then something else needs to be done. Something must be going on to prevent the brain from taking in the information, and that child may need some sign support in addition to the auditory verbal support they're getting. In these cases, we'll make an appropriate referral to another school to provide that support.

SMAKA: Do you have children come from signing families?

HANSEN: Yes, and we have also had some children that were originally in early intervention programs with an emphasis on sign, maybe because of their proximity to such a program. Parents will select the Summit Speech School because they're choosing an auditory oral program.

We have had some parents tell us it is convenient to know a few signs to communicate with their children in the few situations where equipment may be off, such as at the beach. So they use some signs in that respect, but it is not their primary focus.

SMAKA: It sounds like you both are very busy with all the programs going on here.

HANSEN: Yes. Pam and I have also been teaching for the last two years. I have been teaching educational audiology to the third year doctoral students at Montclair State University, and Pam has been teaching aural rehabilitation to graduate students in speech language pathology from Montclair State and from Seton Hall University.

One summer we taught educational audiology to speech language pathology students. We think this is an important course that is not currently emphasized in a lot of programs. Many speech language pathology students getting ready to graduate are not comfortable looking at audiograms and are not confident reading them. In fact, I had one of my students recently say to me, "This is an elective and I really think it should be a required course."

PASKOWITZ: It's hard. When the speech path students graduate and go to work in a school system, they will likely be responsible for the children with hearing impairment in that school system. The school district will say, "You're the speech therapist. You take care of the FM system. You take care of the cochlear implant". The school district is going to assume knowledge and training that the speech language pathologist may or may not have.

It is difficult to teach all the necessary information in one course, or even in two courses. Many students may only have an introduction to audiology course, and maybe an educational audiology course. That's not enough. They need to know what they don't know, and who to call. I give my students resources so they know who to contact for assistance and so they can follow through with issues that come up.

HANSEN: In addition to working with audiology and speech-language pathology students, we recently started training pediatric residents from a local hospital.

PASKOWITZ: Pediatricians have no training in hearing loss. Several residents came here on a rotation as part of their training. It's only a three hour session, but in three hours, again, we can say to them, "This is what you need to know. This is what you don't know. Here's a notebook with more information."

SMAKA: What kind of information do you give them?

PASKOWITZ: The very first thing we get through to them is that a parent knows her child best. When a parent says, "I think my child's not hearing," don't say, "Let's wait until he's two."

HANSEN: Or, do not say "He's a boy. Boys are slow to speak."

PASKOWITZ: We are still tailoring the program but it's been successful so far. We talk about syndromic and non-syndromic hearing loss. On the tour they will see cochlear implants and hearing aids and have an opportunity to talk with our children.

These residents may be the primary physician of a child with a hearing loss. They may be the one making the recommendation or referral for audiology services, for a cochlear implant evaluation and so forth. It's my hope that other hospitals that do resident training will collaborate with a school in the area for this type of information.

SMAKA: It seems like important outreach and I wish you much success with it.

Ellen and Pam, it's been a pleasure visiting the school today. Thanks for all your time and for the great discussion.

PASKOWITZ: Thank you, Carolyn. It's been our pleasure as well.

HANSEN: Thank you, Carolyn.

For more information about Summit Speech School, please visit www.summitspeech.com/