AIOU Solved Assignment 1&2 Code 680 Autumn & Spring 2023

AIOU Solved Assignments code 680 Autumn & Spring 2023 Assignment 1& 2  Course: General Introduction to the Hearing Impairment (680)   Spring 2023. AIOU past papers

General Introduction to the Hearing Impairment (680)   Semester
Autumn & Spring 2023

AIOU Solved Assignment 1& 2 Code 680 Autumn & Spring 2023

Q.1   Degree of hearing loss is important for the educational rehabilitation of hearing impaired students at any level. Discuss the different levels of hearing loss and suggest an educational rehabilitation plan for the hearing impaired students with mild-moderate hearing loss.

Children’s reactions to trauma can often be misunderstood as ‘difficult’ or naughty’ behaviour. It’s normal to find this frustrating, but expressing anger, or blaming the child for this behaviour might make things worse. Instead, try the following strategies.

  1. Reassure the child that he or she is safe and cared for.
  2. Listen and talk to the child about the trauma. Like adults, children and teens often find what they don’t know to be more frightening than the reality.
  3. Give the child special attention; for younger children, prioritise attention at bedtime.
  4. Encourage the child to express their emotions – this is part of the healing process, and can happen through a variety of creative ways, like drawing.
  5. Enjoy activities together as a family.
  6. Keep family roles clear – don’t expect children or teens to take on too much responsibility, but don’t become overprotective either.

Try to understand if they can’t do what is usually expected of them, like going to school, but talk about how they will get back to their normal routine as soon as possible.

Encourage them to talk openly about how they have been feeling since the traumatic event. Try to get an idea about any worries they may have or difficulties they are experiencing. Provide comfort and support and let them know that lots of people struggle with unwanted thoughts, feelings and memories after a traumatic event. But also let them know that you are there for them, and that there is extra help available.

If you feel your child is not improving after using some of the strategies discussed here, or if they are having problems managing their feelings, getting along with others or doing their daily activities, take the child to your GP and ask them to tell the GP about what is troubling them. They may or may not be concerned about the trauma itself – sometimes children and teenagers find it easier to talk about other difficulties, rather than focus on the trauma itself.

If your GP is concerned that your child may be suffering from posttraumatic stress disorder (PTSD) or another trauma-related problem, he or she can arrange for a referral to a child and adolescent counsellor who specialises in helping children and teenagers who have been affected by a traumatic event.

Usually the counsellor will begin with a thorough assessment of your child’s behaviour and emotions. This will involve speaking to you and your child, and perhaps other family members, as well as your child’s teachers.

The counsellor will also want to know how other family members are coping. The counsellor should explain the diagnosis and the treatment options available to you and your child in words that you both understand, so that you are informed about how and why a treatment can work, and feel ready to participate in it. A person with a hearing impairment has a full or partial loss of the ability to hear and discriminate sounds. This is due to an abnormality in the structure and/or functioning of the ear. A Hearing Impairment is described in terms of the degree of hearing loss (e.g. mild to profound) and the type of hearing loss (e.g. permanent – sensori-neural, not permanent – conductive hearing loss, or a mixed hearing loss which is a combination of both). Hearing Impairment can be caused by the following:

  • Genetic factors (e.g. hearing loss in the family).
  • Infections during pregnancy (e.g. cytomegalovirus, rubella, herpes or syphilis), toxins consumed by the mother during pregnancy or other conditions occurring at the time of birth or shortly thereafter.
  • Premature birth
  • Childhood infections (e.g. measles, chicken pox).
  • Head trauma after birth.
  • Otitis Media (i.e. middle ear infection) due to nasal congestion.

What are the common features of a hearing impairment?

  • Speech sound system is delayed and the child is not developing sounds appropriately.
  • Frequent or re-occurring ear infections.
  • A family history of hearing impairment.
  • Difficulties attending and listening.
  • Delayed language skills
  • Performing poorly at school.
  • Lack of response to loud, sudden noises.
  • Poor coordination

Common difficulties often (but not always) experienced by the child with a hearing impairment?

  • Language delay/disorder
  • Speech delay/disorder
  • Sensory processing
  • Attention and listening difficulties
  • Behavioural difficulties
  • Gross motor difficulties due to middle ear dysfunction affecting balance.
  • Difficulties with reading and spelling.

Management strategies that help support the child with a hearing impairment (at preschool, school and/or home):

  • Referral to an ENT (Ears, Nose and Throat Specialist) or audiologist for grommets or hearing aids.
  • Providing those involved with the child information about the child’s level of understanding so that the language used is at an appropriate level for the child to understand.
  • Set up an individualised plan with parents/carers that have small achievable speech and language goals to help develop the child’s language skills.
  • Provide the child with strategies to manage situations when they don’t understand (e.g. teaching them to put up their hand when they don’t understand, teaching some standard questions to ask when needed).
  • Liaison with educational staff to provide information to be incorporated into an education plan and/or implementing ideas/suggestions/activities to help improve the child’s speech and language skills and ability to access the curriculum.
  • Use fun play-based activities or games to help motivate the child to learn.
  • Use simple and concise information.
  • Use visuals to supplement auditory language (e.g. pictures, signs, gestures).

Occupational Therapy approaches and activities that can support the child with a hearing impairment and/or their carer’s include:

  • Child’s abilities: Observing the child during play and formal assessment to determine the child’s abilities with gross motor (whole body) tasks and what they find difficult and then making recommendations for management.
  • Devise goals: Setting functional goals in collaboration with the child, parents and teachers so that therapy has a common focus beneficial to everyone involved.
  • Educatingparents, carers and teachers about Hearing Impairment, the age appropriate skills a child should be demonstrating and providing management strategies/ideas to assist the child in the home, at school and in the community.
  • Sensory processing: Improving sensory processing to ensure appropriate attention and arousal to attempt the tasks as well as ensuring the body is receiving and interpreting the correct messages from the muscles in terms of their position and relationship to each other.
  • Multi-sensory approach: Using a multi-sensory approach to learning new skills.
  • Modellingtasks visually and using hands on adjustment techniques to aid body awareness for the child.

Speech Therapy approaches and activities that can support the child with a hearing impairment and/or their carer’s include:

  • Speech and language assessment to determine the child’s speech (i.e. articulation) and language (i.e. understanding and use of language) skills to develop appropriate management strategies.
  • Daily activities: Providing parents with interaction strategies to develop language which can be implemented during daily activities within the home.
  • Multi-sensory approach: Using a multi-sensory approach (e.g. sight, taste, smell, touch) to learn new words and concepts.
  • Child’s interests: Using the child’s interests to help develop their language skills.
  • Fun games: Using fun play-based activities or games to help motivate the child to learn.
  • Visuals(e.g. pictures, words) can be used to help understanding and use of language where appropriate.
  • Books: Teaching about the use of books and stories to aid language development.
  • Articulation: Improving articulation of specific speech sounds within words.
  • Alternative forms of communication: Developing alternative ways of communicating (e.g. sign language, the Picture Exchange Communication System (PECS), voice output devices).
  • Liaisingwith educational staff and other professionals involved in the child’s care regarding the nature of the difficulties and ways to help the child to access the curriculum.

Why should I seek therapy for my child with a hearing impairment?

Diagnosis alone is NOT the solution. It simply opens the door to getting the help that is needed by arming all involved with the relevant information.

The ‘help’ still needs to be provided. The help that is provided (at least from a therapy perspective) will reflect:

  • First and foremost what medical intervention is needed.
  • What the parents/teachers/carers biggest concerns are for the child (i.e. what are the most significant functional challenges).
  • The specific areas that are problematic to the child (which will vary even within children with the same diagnosis).
  • The capacity of the child’s environments to meet the child’s needs.

If left untreated the child with a hearing impairment may have difficulties with:

  • Following instructionswithin the home, kindergarten or school environment.
  • Vocabularywhereby a child cannot clearly get their message across due to limited word knowledge.
  • Learning to talk, speech intelligibility and clarity.
  • Self esteem and confidencewhen they realise their skills do not match their peers.
  • Bullyingwhen others become more aware of the child’s difficulties.
  • Self regulation and behaviouras the child is unable to regulate themselves appropriately to settle and attend to a task for extended periods of time.
  • Accessing the curriculumbecause they are unable to attend to tasks long enough to complete assessment criteria.
  • Anxiety and stressin a variety of situations leading to difficulty reaching their academic potential.
  • Academic performance:Developing literacy skills such as reading and writing and coping in the academic environment.
  • Academic assessment:Completing tests, exams and academic tasks in higher education.

More specific implications of not seeking treatment will be influenced by the common difficulties that are most influencing your individual child.

For more information see the relevant fact sheets under areas of concern or refer to the other relevant resources section below.

What does the diagnosis of a hearing impairment really mean for the child?

Diagnoses are used to label a specific set of symptoms that are being experienced by a child.

This label then helps to narrow down and specifically tailor what:

  • Other issues commonly occur simultaneously.
  • Medication might be appropriate.
  • Therapies might help the child (e.g. Medical, Occupational Therapy, Speech Therapy, Psychology).
  • Course of intervention (medical and/or allied health) might be and what outcome might be expected (prognosis).
  • Can be done to help the child.

A diagnosis helps the child and their carers (parents, teachers, health professionals, carers) to:

  • Access information about the relevant cluster of symptoms.
  • Communicate the salient features of the child’s challenges to all people involved in the child’s care.
  • Possibly interpret certain behaviours differently in light of the diagnosis.
  • Obtain information about what can be done to help the child.
  • Determine specifically where and how to help the child.
  • Access funding or services that might not otherwise be accessible.

AIOU Solved Assignment 1& 2 Code 680 Autumn & Spring 2023

Q.2   Draw a picture of human ear highlighting outer, middle and inner ear. Also explain the functions of different parts of ear.

The anatomy of our hearing or auditory system is extremely complex but can be broadly divided into two parts, one being called ‘peripheral’ and the other ‘central’.

The peripheral hearing system consists of three parts which are the outer ear, the middle ear and the inner ear:

  • The outer ear consists of the pinna (also called the auricle), ear canal and eardrum.
  • The middle ear is a small, air-filled space containing three tiny bones called the malleus, incus and stapes but collectively called the ossicles. The malleus connects to the eardrum linking it to the outer ear and the stapes (smallest bone in the body) connects to the inner ear.
  • The inner ear has both hearing and balance organs. The hearing part of the inner ear and is called the cochlea which comes from the Greek word for ‘snail’ because of its distinctive coiled shape. The cochlea, which contains many thousands of sensory cells (called ‘hair cells’), is connected to the central hearing system by the hearing or auditory nerve. The cochlea is filled with special fluids which are important to the process of hearing.

The central hearing system consists of the auditory nerve and an incredibly complex pathway through the brain stem and onward to the auditory cortex of the brain.


The physiology of hearing, just like its anatomy, is very complex indeed and is best understood by looking at the role played by each part of our hearing system described above.

Sound waves, which are really vibrations in the air around us, are collected by the pinna on each side of our head and are funnelled into the ear canals. These sound waves make the eardrum vibrate. The eardrum is so sensitive to sound vibrations in the ear canal that it can detect even the faintest sound as well as replicating even the most complex of sound vibration patterns.

The eardrum vibrations caused by sound waves move the chain of tiny bones (the ossicles – malleus, incus and stapes) in the middle ear transferring the sound vibrations into the cochlea of the inner ear.

This happens because the last of the three bones in this chain, the stapes, sits in a membrane-covered window in the bony wall which separates the middle ear from the cochlea of the inner ear. As the stapes vibrates, it makes the fluids in the cochlea move in a wave-like manner, stimulating the microscopically small ‘hair cells’.

Remarkably, the ‘hair cells’ in the cochlea are tuned to respond to different sounds based on their pitch or frequency of sounds. High-pitched sounds will stimulate ‘hair cells’ in the lower part of the cochlea and low-pitched sounds in the upper part of the cochlea.

What happens next is even more remarkable because, when each ‘hair cell’ detects the pitch or frequency of sound to which it’s tuned to respond, it generates nerve impulses which travel instantaneously along the auditory nerve.

These nerve impulses follow a complicated pathway in the brainstem before arriving at the hearing centres of the brain, the auditory cortex. This is where the streams of nerve impulses are converted into meaningful sound.

All of this happens within a tiny fraction of a second….almost instantaneously after sound waves first enter our ear canals. It is very true to say that, ultimately, we hear with our brain.

AIOU Solved Assignment 1& 2 Code 680 Autumn & Spring 2023

Q.3   A clinical audiologist is reasonable of measuring and recording of hearing. Explain the responsibilities and functions of clinical audiologist. Also draw a pure tome audiogram with symbols used internationally.

Demonstrating medical necessity is an essential component in documentation for audiology services. Medicare defines medical necessity by exclusion, stating that “services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered” (Centers for Medicare & Medicaid Services [CMS], 2014a). Medicare further itemizes circumstances for reasonable and necessary services in Local Coverage Determinations as “safe and effective, not experimental or investigational . . . , appropriate . . . in accordance with accepted standards of medical practice . . . , furnished in a setting appropriate to the patient’s medical needs and condition; . . . ordered and furnished by qualified personnel” (CMS, 2014b). Medicare stipulates that “the services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a [qualified health care professional]” (CMS, 2014c).

Justification for reasonable and necessary care and medical necessity can be achieved by addressing the following criteria:

  • Reasonable: Services are provided with an appropriate amount (number of times in a day), frequency (number of times in a week), duration (number of weeks or total sessions), and accepted standards of practice.
  • Necessary: Appropriate services are provided for the client/patient’s medical diagnosis and prior level of function.
  • Specific: Services are targeted to particular goals.
  • Effective: Services are provided with an expected functional improvement to be achieved within a reasonable time (or maintenance of function in the case of degenerative conditions), with the client/patient’s prior level of function serving as the baseline.
  • Skilled: Services provided require the knowledge, skills, and judgment of an audiologist.

Relevant documentation for establishing medical necessity may include the following details (ASHA, 2004):

  • Medical/behavioral history—pertinent medical history that influences the audiologic intervention, concise description of client/patient’s functional status prior to the onset of the condition requiring audiology services, and relevant prior audiologic and/or speech-language intervention.
  • Diagnosis of hearing, vestibular, tinnitus, and related disorders—the diagnosis established by the audiologist.
  • Date of onset—date of onset of hearing, vestibular, tinnitus, and/or related disorder.
  • Physician referral/order.
  • Initial evaluation and date.
  • Evaluation procedures used by the audiologist to diagnose hearing, vestibular, tinnitus, and related disorders.
  • Individualized plan of care and date established.
  • Intervention notes/progress notes (frequency depends on payer and facility policy).
  • Updated client/patient status reports concerning the client/patient’s current functional abilities/limitations.

Skilled Services

Medicare (and other plans that adopt Medicare documentation guidelines) stipulate that services eligible for reimbursement must be at a level of complexity and sophistication that requires the specific expertise and clinical judgment of the qualified health care professional.

Unskilled services do not require the unique knowledge and skills of an audiologist. Skilled services that are not adequately documented may appear to be unskilled.

Audiologists use their expert knowledge and clinical reasoning to perform the skilled services listed below. Audiologists

  • analyze medical/behavioral data to select appropriate evaluation tools/protocols to determine hearing/vestibular/tinnitus diagnosis and prognosis;
  • design a client/patient-centered plan of care that establishes device recommendations, long-term and short-term measurable functional goals, and discharge criteria for habilitatative and rehabilitative services;
  • engage clients/patients in practicing communication strategies, with or without devices, while explaining the rationale and expected results;
  • ensure client/patient and family/caregiver participation and understanding of diagnosis, device, intervention plan, communication strategies, and realistic expectations;
  • provide fitting and verification for hearing aid users;
  • provide services related to middle ear implants and bone-anchored hearing devices;
  • provide programming and verification of cochlear implants;
  • train client/patient and others in the use and care of communication systems and/or devices;
  • develop a communication program to be carried out by the client/patient and family/caregiver at home, which may include assistance through technology and computerized learning tools;
  • train caregivers to facilitate carryover for optimal performance of trained skills and/or generalization of skills; and
  • determine when discharge from habilitative or rehabilitative programs is appropriate.
Documenting Skilled Services

Recommendations for documenting skilled services are as follows:

  • Use terminology that reflects the audiologist’s technical knowledge but is still understandable to individuals who are not audiologists.
  • Indicate the rationale for the type and complexity of test or activity.
  • Document results and outcomes with professional interpretations.
  • Document device analysis and programming as well as training provided to the client/patient and family/caregiver on device programming.
  • For a habilitative/rehabilitative program, report objective data showing progress toward goals, such as accuracy of task performance or level of independence in task completion.
  • Specify counseling or education provided to client/patient and family/caregiver as well as client/patient and family/caregiver response.
  • Clarify decision making regarding modifications to plan of care.

Documentation for Clinical Management

Clinical documentation includes justification of the following service attributes:

  • Medical necessity — Are the services provided reasonable and necessary to address a clinical question?
  • Skilled services — Are they services that can be provided only by a qualified audiologist?
  • Functionality — Do the recommendations or services address goals that are relevant to the client/patients’ educational or vocational needs, safety, health, and independence in their environments and to their specific communication needs and partners?
  • Value — Do the services improve quality of life and save costs through prevention and intervention, increased safety, or increased independence and participation in activities of daily life?

Audiologists will be increasingly accountable for justifying the value of their contribution to the coordinated care of the interdisciplinary/interprofessional team and to the client/patient’s functional outcomes as payment models move away from fee-for-service and toward bundled care and efficiency-based-outcome and quality-of-life models.

Components of Clinical Documentation

Required components of clinical documentation vary and are dependent upon factors such as setting, service(s) provided, and legal factors. Documentation of all clinical interactions, whether diagnostic or interventional, will recount the following details:

  • Date of encounter
  • Procedures performed
  • Client/patient and family/caregiver participation
  • Subjective and objective data
  • Clinical interpretations
  • Recommendations
  • Accommodations and modifications to clinical procedures
  • Client/patient and family/caregiver counseling and education
  • Credentials and signature of practicing clinician


Progress Note

progress notes is written for clients/patients who are receiving regular habilitation or rehabilitation. Progress notes are composed at given intervals (often determined by payers) and assess the progress toward long-term and short-term goals. These notes typically include

  • skilled services provided;
  • client/patient response, including any home programming;
  • objective measures of progress toward functional goals;
  • changes to the goals or plan of care, if appropriate;
  • number of client/patient encounters and location(s);
  • date(s) of service; and
  • provider signature and credentials.
Discharge Summary

discharge summary may be required to detail the intervention provided, the reason for discontinuing services, and the client/patient status at the time of discharge if the plan of care covers multiple client/patient encounters (e.g., early intervention services). Not all cases will require a discharge summary.

Discharge summary notes typically include

  • goals and progress toward goals;
  • skilled services provided;
  • objective measures (e.g., pre-intervention and post-intervention evaluation results, outcomes measures);
  • functional status;
  • client/patient and family/caregiver education provided;
  • reason for discharge;
  • recommendations for follow-up;
  • date(s) of service; and
  • provider signature and credentials.

Documentation to Support Reimbursement


Although Medicare does not reimburse audiologists for audiologic treatment services (e.g., vestibular rehabilitation, auditory rehabilitation), Medicare documentation guidelines may serve as minimum standards adopted by other payers. In addition to the documentation requirements described above, Medicare also requires that documentation and claims reporting comply with requirements related to the Physician Quality Reporting System (PQRS).


Medicaid is a joint federal- and state-funded program to assist states in providing medical care to low-income individuals and to those who are categorized as “medically needy.” Medicaid services are included as part of a free and appropriate public education to those children who are eligible. Medically necessary services may be delivered in health care settings or in schools. Documentation requirements for Medicaid may follow Medicare guidelines. State-specific guidelines can be found in the state’s Medicaid plan and/or Medicaid guidance documents (e.g., the state provider handbook). For more information, go to ASHA’s Medicaid Toolkit.

Private Insurance

Private payers do not use a universal documentation template, and requirements vary. Documentation typically includes the reason for the client/patient visit, services completed, findings, and recommendations in a way that justifies the diagnosis and procedure codes (see Coding for Reimbursement). Medicare documentation requirements may be useful as a set of basic guidelines.

Coding/Billing to Support Reimbursement

Correct coding is the key to submitting valid claims for reimbursement of health care services. Proper clinical documentation provides the justification for the codes submitted. If information presented in the documentation is inadequate or does not align with the billing codes, claims may be denied. The Health Care Common Procedure Coding System (HCPCS) and International Classification of Diseases (ICD) are the primary coding systems used by health care providers and third-party payers in the United States.

  • HCPCS Level I codes, more commonly referred to as Current Procedural Terminology (CPT®; developed by the American Medical Association) codes, are used to describe procedures or services (e.g., audiologic assessment, aural rehabilitation). CPT codes for audiologists are available on the ASHA website and are updated annually.
  • HCPCS Level II codes, typically called HCPCS (“hick picks”) codes, are used to report supplies, equipment, and devices provided to clients/patients (e.g., hearing aids). HCPCS Level II Codes for audiology related devices are available on the ASHA website and are updated quarterly.
  • ICD codes are used to report diagnoses or disorders (e.g., noise-induced hearing loss, tinnitus). ICD Diagnosis Codes are available on the ASHA website and are updated annually.

Procedure and diagnosis codes are recorded on a claim form submitted either electronically or on paper to third-party payers. Medicare, Medicaid, and most private health insurance plans use the CMS-1500 [PDF] claim form for noninstitutional providers (i.e., office setting) and the CMS-1450 [PDF]—or UB-04—form for institutional providers (e.g., hospital, comprehensive outpatient rehabilitation facility). See also Medicare Part B Claims Checklist: Avoiding Simple Mistakes on the CMS-1500 Claim Form.

Documentation in Educational Settings

Documentation in educational settings is used to convey essential clinical information about each student’s diagnosis, intervention, and outcomes, and to address the questions that payers and/or stakeholders may ask about each student encounter:

  • Is it educationally and/or functionally relevant?
  • Is it a service requiring the knowledge and skills of an audiologist?
  • How does this service add value to the student’s education, interdisciplinary care, and/or overall health?

The structure of the documentation must ensure compliance with the Individuals with Disabilities Education Act (IDEA; IDEA, 2004) and state regulations. High-quality documentation protects school districts and service providers in mediation and due process situations. IDEA requires regular reporting of students’ progress on individualized education program (IEP) goals supported with data. Educationally oriented documentation includes diagnostic and clinical assessment results as well as the significance of the diagnostic outcomes regarding the child’s ability to learn in a classroom or other educational setting. An educationally oriented comprehensive plan of care is developed when intervention is necessary.

When billing Medicaid for services provided in the school setting, the standards of Medicaid documentation apply. Separate documentation may be needed to address educational requirements (e.g., for the IEP).

AIOU Solved Assignment 1& 2 Code 680 Autumn & Spring 2023

Q.4   What do you comprehend the concept of bone conduction? What are the principles of the bone conduction test and how we record its information on an audiogram?

Bone conduction is instrumental in the efficacy of a number of iLs products, including the iLs Focus, VoicePro and Dreampad. You are actually receiving bone conduction all the time. The easiest way to understand this is to think about how your voice sounds when you speak versus how it sounds when recorded. Have you ever noticed how your recorded voice sounds different to you? Perhaps it sounds “thin” or “tinny.” Usually it doesn’t sound similar to how you hear your voice. Yet, if you were to ask others, they’d say, “Yes, that sounds like you.” Air conduction refers to sound from the outside carried by air waves from the outer ear and transferred to electrical waves in the inner ear. Bone conduction refers to sound conducted as subtle vibration along the bones to the inner ear housing the organs of hearing and balance. The sound vibration actually activates both the sense of hearing and the organ of balance. The vibration, in fact, is carried through the entire skeletal structure.

iLs makes use of this natural process by inserting a bone conductor into the top of the headphones. The low frequencies of music have more acoustical power and generate more vibration than high frequencies. Therefore, lower frequencies will have a greater effect on body organization and the sense of being grounded.

Bone conduction is an important tool to increase activation to the vestibular system. This enhanced activation results in improved body awareness, balance, coordination and increased muscle tone.

Its uses both air and bone conducted sound in the iLs Focus and VoicePro systems because of the therapeutic goals when using these systems. One goal is to train the auditory system to discriminate and process the entire range of language frequencies (air conduction). Other goals include input to the vestibular/cochlear organ to provide a grounding/calming influence and to help with body organization (bone conduction).

Sound affects our whole nervous system and bone-conducted sound may have a more direct influence because of the subtle physical vibration. Two important areas affected by bone conduction are the vestibular system and the vagus nerve.

Sound travels in waves through the air. Normally, sound waves travel through several structures in the ear, before being translated and transmitted through our nervous systems to our brains. First, the waves enter the outer ear, or pinna, which is the big flappy piece of cartilage that helps to focus the sound. From there, the sound goes into the air-filled middle ear, which includes the auditory canal and the eardrum, a flap of skin that vibrates when exposed to the energy from sound waves. On the other side of the eardrum, there are three small bones, the ossicles, which are attached to it. They transmit the vibration to the cochlea, a fluid-filled structure that takes those vibrations and converts them to electrical impulses that are sent along the auditory nerve to the brain.

But that’s not the only way our body can process sound. Sound waves can also be transmitted through the bones in your head. When the bones vibrate, the sound reaches the cochlea, just as it would by going through the middle ear and eardrum, and results in the same sort of nerve impulses being transmitted to your brain. This method of sound transmission is called bone conduction.

The great 18th- and early-19th-century composer Ludwig Van Beethoven, who suffered hearing loss apparently caused by thickening of the structures in his middle ear, may have been one of the first people to develop a bone-conducting device help him hear music. He attached a rod to his piano and then connected it to his head, so that it transmitted the vibration of his playing directly to his cochlea. Bone-conducting headphones are built around this same concept.

Hearing loss generally is categorized into two types: conductive and sensorineural. Conductive hearing loss occurs when a condition of the outer or middle ear prevents sound from being conducted to the cochlea in the inner ear. Sensorineural hearing loss involves a problem with either the sensory transducer cells in the cochlea or, less commonly, the neural pathway to the brain. In some instances, conductive and sensorineural hearing loss occur together, resulting in so-called mixed hearing loss. Whereas conductive hearing loss often can be corrected via surgery and is relatively common in childhood, sensorineural hearing loss usually is permanent. Therefore, it is important for the audiologist to distinguish between the two conditions.

One method of differentiating between conductive hearing loss and sensorineural hearing loss is to compare air-conduction and bone-conduction hearing threshold levels. This involves measuring hearing sensitivity by using two different types of earphone. In air-conduction testing, a pure tone is presented via an earphone (or a loudspeaker). The signal travels through the air in the outer ear to the middle ear and then to the cochlea in the inner ear. In bone-conduction testing, instead of using an earphone, an electromechanical earphone is placed on the skull. This allows for stimulation of the cochlea via mechanical vibration of the skull with almost no stimulation of the outer and middle ear.

Normal hearing individuals typically have a hearing threshold level close to 0 dB for both air and bone conduction. Individuals with a hearing disorder of any part of the auditory pathway have poor air-conduction thresholds. Poor air-conduction threshold is the primary indication of conductive hearing loss, since abnormalities of the conduction mechanism have relatively little effect on bone-conduction measurements. In sensorineural hearing loss, the thresholds for both air conduction and bone conduction are affected such that the air-bone gap (air conduction minus bone conduction) is close to zero. The presence of an air-bone gap signifies conductive hearing loss.

The dynamic range between the threshold of hearing and loudness discomfort level is around 100 dB in normal hearing listeners. Listeners with sensory hearing loss have raised hearing thresholds, but their loudness discomfort levels are essentially similar to those of normal hearing listeners. Listeners with a sensory hearing impairment have a reduced dynamic range and experience loudness recruitment, or an abnormal rate of loudness growth characterized by an abnormally disproportionate increase in loudness for a small increase in sound intensity. This has implications for the design of hearing instruments, since nonlinear amplification, in which soft sounds require greater amplification than loud sounds, is required. Although a nonlinear hearing instrument can compensate by increasing amplification for soft sounds, it cannot compensate for the loss of suprathreshold abilities such as impaired frequency resolution. As a result, background noise remains a problem for many listeners. Between age six months and two or three years, the measurement technique of choice usually is visual reinforcement audiometry. This involves pairing a head turn response to a sound with an interesting visual reward, such as a flashing light or an animated toy animal. Once this classical conditioning has been established, operant conditioning then takes place, in which a visual reward is presented after an appropriate sound-elicited head turn. This technique is used to determine the minimum response level that will elicit a head turn. Although it is usual to attempt ear-specific measurements in children, in some cases earphones are not tolerated, requiring that the signal be presented from a loudspeaker; this is known as sound field audiometry. In general, infants tend to be more sensitive to high-frequency sounds than low-frequency sounds; whether this is related to physiological development or is associated with other factors, such as infant-directed speech (which is characterized in part by high-frequency pitches), is unclear. Before six months, behavioral testing is of limited use in determining hearing threshold levels. However, a small amount of sound is generated in the healthy cochlea, and this otoacoustic emission can be measured with a small sensitive microphone in the ear canal. The normal response from a healthy ear forms the basis of a clinical procedure that can be used to screen hearing in a newborn. If no otoacoustic emission can be recorded, event-related potentials (brain activity produced by a sensory or cognitive response to a stimulus) can be used to estimate hearing sensitivity. This involves the measurement of electrical potentials via recording leads attached to the scalp. The method of choice in infants is the auditory brainstem response, because this can be obtained during sleep. A typical procedure is to commence at a high level and reduce this until the evoked response can no longer be detected. The presence of a response is based on the tester’s subjective interpretation of the waveform. Event-related potentials can also be used to estimate hearing sensitivity in adults who are unable or unwilling to provide reliable information via pure-tone audiometry. Newborns who do not pass initial hearing screening may undergo auditory steady state response testing, in which brain activity in the sleeping infant is measured in response to tones of differing frequency and intensity. The presence of a steady state response is determined on the basis of statistical data.

A commonly used procedure that provides information about the condition of the tympanic membrane (eardrum) and the middle ear is known as tympanometry. Tympanometry frequently is used to evaluate the eardrum in children who are prone to ear infections, in which fluid accumulates in the normally air-filled middle ear space. During the procedure, a pure tone is produced, and air pressure is changed inside the ear with a handheld instrument. The procedure is based on the principle that some sound entering the ear canal is reflected back from the eardrum; the reflected sound can be measured with a sensitive microphone. When the eardrum is stiff, air pressure in the ear canal is increased, resulting in an increased reflection of sound by the eardrum. Stiffening of the eardrum is associated with various conditions of the middle ear. The vestibular system of the inner ear functions in the perception of balance and motion. Sudden changes in the function of the vestibular organ can result in rotatory vertigo, which gives the illusion that the environment is spinning around. Useful information about vestibular function can be obtained by observing eye movements during certain visual and vestibular stimulation. The audiologist is particularly interested in the presence of a slow-quick oscillatory movement of the eyes known as nystagmus. This eye movement will be present spontaneously after a change in vestibular function and may continue for days or weeks until the brain has had time to compensate. Nystagmus may also be provoked by changes in body position, such as rising out of bed in the morning. The sensitivity of the right and left vestibular organs can be compared in a caloric test, in which the external ear canal is irrigated with hot or cold water to induce a response. In vestibular assessment, a force platform may be used to measure body sway, which can provide information about the use of the visual, vestibular, and proprioceptive systems for balance function and postural control.

Rehabilitative procedures generally involve head and eye exercises that aid the central compensation mechanism. In severe cases, surgery may be considered. Surgical procedures to treat vestibular disorders generally are either corrective, attempting to stabilize inner ear function, or destructive, removing the parts of inner ear structures responsible for the patient’s condition. An example of a corrective procedure is endolymphatic sac decompression, which is used to relieve pressure on the vestibular system, particularly in the case of Ménière disease. Examples of destructive procedures include labyrinthectomy (removal of the balance and hearing organs of the inner ear) and vestibular nerve section (the vestibular nerve is cut to prevent the transmission of balance information to the brain).

AIOU Solved Assignment 1& 2 Code 680 Autumn & Spring 2023

Q.5   In Unit 5 we learnt importance of pre-lingual period for the development of language. How we can evaluate the consequences of prelinguistic hearing impairment for all aspects of development.        

Spoken communication is uniquely human. If the sense of hearing is damaged or absent, individuals with the loss are denied the opportunity to sample an important feature of their environment, the sounds emitted by nature and by humans themselves. People who are deaf or hard-of-hearing will have diminished enjoyment for music or the sound of a babbling brook. We recognize that some deaf and hard-of-hearing children are born to deaf parents who communicate through American Sign Language. Without hearing, these children have full access to the language of their home environment and that of the deaf community. However, the majority of deaf and hard-of-hearing children are born to hearing parents. For these families, having a child with hearing loss may be a devastating situation. The loss or reduction of the sense of hearing impairs children’s ability to hear speech and consequently to learn the intricacies of the spoken language of their environment. Hearing loss impairs their ability to produce and monitor their own speech and to learn the rules that govern the use of speech sounds (phonemes) in their native spoken language if they are born to hearing parents. Consequently, if appropriate early intervention does not occur within the first 6-12 months, hearing loss or deafness, even if mild, can be devastating to the development of spoken communication with hearing family and peers, to the development of sophisticated language use, and to many aspects of educational development, if environmental compensation does not occur. Hearing loss can affect the development of children’s ability to engage in age-appropriate activities, their functional speech communication skills, and their language skills. Before we consider the effects of hearing loss on this development, we will review briefly the extensive literature on the development of speech and language in children with normal hearing. Although the ages at which certain development milestones occur may vary, the sequence in which they occur is usually constant.

Language Skills

Language studies have described vocabulary and grammatical development of children with normal hearing. Studies of grammatical development have focused on both word structure (e.g., prefixes and suffixes), termed “morphology,” and the rules for arranging words into sentences, termed “syntax.” Vocabulary development up to young adulthood is estimated at roughly 1,000 word families per year, with vocabulary size estimated at approximately 4,000-5,000 word families for 5-year-olds and 20,000 word families for 20-year-olds (see Schmitt, 2000, for discussion). A word family is defined as a word plus its derived and inflectional forms. Most morphological and syntactic skills are fully developed by the age of 5 years, and grammatical skills are fully developed by age 8 (Nober and Nober, 1977). By age 10 to 12, most children with normal hearing have reached linguistic maturity (Quigley and Paul, 1984). In summary, by age 4½ years, children with normal hearing are producing complex sentences. Although a majority of the speech sounds in English are mastered by age 4, and most of the grammatical categories by age 5, it is not until age 8 that a normally hearing child has fully mastered grammar and phonology and has an extensive vocabulary (Nober and Nober, 1977).

Children with Hearing Loss

A review of speech and language development in children with hearing loss is complicated by the heterogeneity of childhood hearing loss, such as differences in age at onset and in degree of loss; we review these complicating factors separately following a more general overview. Mental and physical incapacities (mental retardation, cerebral palsy, etc.) may also coexist with hearing loss. Approximately 25-33 percent of children with hearing loss have multiple potentially disabling conditions (Holden-Pitt and Diaz, 1998; McCracken, 1994; Moeller, Coufal, and Hixson, 1990). In addition, independent learning disabilities and language disabilities due to cognitive or linguistic disorders not directly associated with hearing loss may coexist (Mauk and Mauk, 1992; Sikora and Plapinger, 1994; Wolgemuth, Kamhi, and Lee, 1998). For example, Holden-Pitt and Diaz (1998) reported the following incidences of additional impairments in a group of children with some degree of hearing loss: The coexistence of other disabilities with hearing impairment may impact the way in which sensory aids are fitted or the benefit that children receive from them (Tharpe, Fino-Szumski, and Bess, 2001). A recent technical report from the American Speech-Language-Hearing Association stated that pediatric cochlear implant recipients with multiple impairments often demonstrate delayed or reduced communication gains compared with their peers with hearing loss alone (American Speech-Language-Hearing Association, 2004).

In this chapter, we focus on speech and language development in children with prelingual onset of hearing loss (before 2 years of age) without comorbidity. However, it should be kept in mind that the presence of multiple handicapping conditions may place a child at greater risk for the development of communication or emotional disorders (Cantwell, as summarized by Prizant et al., 1990). In addition, these children may require adaptations to standard testing routines to accommodate their individual capacities.

Natural acquisition of speech and spoken language is not often seen in individuals with profound hearing loss unless appropriate intervention is initiated early. One of the primary goals in fitting deaf or hard-of-hearing children with auditory prostheses (hearing aid or cochlear implant) is to improve the ease and the extent to which they can access and acquire speech and spoken language. It should be kept in mind that the children under discussion typically are not born to deaf parents; those children may acquire American Sign Language as their native language.

Neonatal hearing screening programs have proven effective as the first step in early identification of infants with congenital hearing loss. These programs identify infants at risk for a mild or more serious hearing loss. It is important to note that screening identifies only which infants are in need of a more complete assessment to determine if hearing loss exists. Infants failing this screening require a diagnostic audiological assessment by a qualified audiologist to confirm the presence of hearing loss and determine the exact type and degree of hearing loss in each ear. Results of the diagnostic evaluation are used to determine the degree of disability, to determine eligibility for rehabilitation programs and financial assistance, and to form the basis for fitting of amplification and placement in appropriate educational settings.

Although the screening process for newborn hearing loss is excellent, it is not perfect. Children with mild hearing loss or hearing loss in restricted frequency regions may pass the screening. Some children develop significant permanent hearing loss after the newborn period, which is not detected by the screening. Infants with neural hearing loss, such as auditory neuropathy, will pass a screening if an OAE test alone is used for screening (Sininger, 2002). Infants with late-onset hearing loss will be missed in the newborn screening; and constant surveillance is needed by the medical community to find these infants and begin remediation as soon as possible (Joint Committee on Infant Hearing, 2000).

The screening and diagnostic testing process is designed to expedite intervention for children with hearing loss and maximize the opportunity to provide audition during critical learning periods (Sininger, Doyle, and Moore, 1999; Yoshinaga-Itano et al., 1998). The goal of early hearing detection and intervention programs is to identify hearing loss and begin intervention including fitting of hearing aids at or before 6 months of age.

Assessment of hearing loss in infants requires age-appropriate procedures. Infants under 6 months of age cannot give an accurate response to sounds at threshold levels, regardless of their ability to detect them. These infants require an audiological test battery based on objective physiological tests that reveal threshold-level responses, as well as information regarding the functioning of the peripheral auditory system.


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