ELF – Early Listening Function Discovery Tool for Parents and Caregivers of Infants and Toddlers (4 Months to 3 Years) ELF - Early Listening Function

Home , Elf

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF – Early Listening Function Discovery tool for parents and caregivers of infants and toddlers (4 months to 3 years) ELF - Early Listening Function

User’s Manual

This manual is for pediatric audiologists and early intervention service providers who are working with families of infants and toddlers with hearing impairment. The Early Listening Function instrument has been designed to obtain an indication of the functional use of hearing in very young children.

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

The ELF has three primary purposes:

1. Parent involvement and hearing loss, the ELF can assist the empowerment parents in recognizing the limita- With universal newborn hearing tions of the hearing loss, which may screening, infants with hearing loss motivate them to consider amplifi ca- are being identifi ed in the fi rst month tion use seriously. Children with the of life and parents are typically not best language outcomes are those prepared for the diagnosis of hearing who have parents that are intimately loss in their newborn.The adjustment involved in all areas of early interven- to having a child with hearing loss tion and hearing loss management. and the eventual acceptance of the As the child’s pediatric audiologist, hearing loss as an integral feature you have entered into a partnership of the child’s life comes with the to manage the child’s hearing needs understanding of how the hearing as they grow and develop throughout loss may aff ect the child. Gaining the childhood. parents’ involvement and participation in the discovery process of how the child functions auditorily can be 2. Estimating amplifi cation very benefi cial to the adjustment and benefi t acceptance process of the parents. Although diagnostic procedures are It also establishes a partnership improving for young infants, there between the parents and audiologist remains a degree of uncertainty about as the team who identifi es the child’s the exact hearing thresholds of most hearing abilities and current limita- infants at the time they are fi t with tions and growth (change) over time. their fi rst hearing instruments. The Through this participation, parents range of technologies available to au- are empowered to be involved in diologists to choose from when fi tting observing their child’s hearing be- young children has also increased. havior. This can then lead to a deeper Real-Ear-to-Coupler Diff erence (RECD) appreciation of the nature of commu- measures provide targets for hear- nication and to readiness to become ing aid fi tting. With involvement and informed about eff ective parent-child careful observation by the parents interaction strategies and techniques and daily caregivers of the child, to facilitate auditory development. useful information can be gathered For children with mild or unilateral that can develop confi dence in the

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

optimal adjustment of the hearing child during communication and how instruments for daily use. The ELF can the listening bubble may aff ect the also be useful in determining if a per- child’s responses to auditory stimuli, sonal FM system would be of benefi t may assist in realistic step-by-step as the ELF activities raise the aware- auditory skills goal setting. ness of the parents about the daily Although the ELF listening activi- situations and listening conditions ties are detection activities, other would benefi t from FM system use. activities encouraging identifi cation, The ELF can also be used as a pretest discrimination, and comprehen- and posttest for comparing hearing sion of sound can be introduced in instruments or FM system benefi t. the same manner (close, far, quiet, typical,noisy) once the parent has become accustomed to the struc- 3. Tracking improvements in ture of presenting the ELF listening auditory development activities. Knowing the child’s typical Understanding the eff ect of hearing auditory behavior can also help the loss on communication access in parent in detecting possible changes daily situation by the parents and in hearing status due to otitis media caregivers can only support the even- with eff usion or hearing loss progres- tual communication outcomes of the sion. Finally, hearing loss is invisible child with hearing loss. Development and is diffi cult to explain in a clearly- of verbal language depends on con- understood manner. The structure of sistent communication access. For the ELF may provide parents a clear parents that choose an auditoryoral and meaningful way to describe their or auditory-verbal communication op- child’s hearing impairment to family tion for their child, a strong focus on and friends so that they may respond auditory development is necessary. knowledgably to a comment like “I’ve Like any other developing part of the seen the baby hear and don’t think body, the auditory system de-velops he needs the hearing aids.” as it is stimulated consistently over time. The ELF can assist parents and early interventionists in tracking a child’s functional use of early auditory skills in the home. Recognizing the importance of proximity to the

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

Appropriate Use of the ELF

Audiologist or early interventionist should discuss these points with parents prior to giving them the ELF

The premise of the ELF is to identify if Listening Activities a child is able to detect certain types The child must not be able to see of sounds from diﬀ erent distances the person making the sounds, their in both quiet and noise. Infants shadow, or be able to detect the like to listen to sounds and voices, sound by feeling their breath, air however, the behavioral response moving, or other vibrations. when a 1-month old perceives sound will be somewhat diﬀ erent than an These listening activities are not older infant. In order for the ELF to “calibrated” sounds. However, it is provide appropriate results, parents important that the parent or car- need to have a clear idea of what the egiver attempt to use the same sound activities are, how to do them, and intensity during all presentations. For what responses to expect. Discuss example, if a child responded to a this information with the parents to whisper at 3 feet but not at 6 feet, the prevent their possible frustration or parent should not make the whisper misunderstanding of what they have louder to obtain a response at 6 feet. observed. Some parents may need to Only if the child responded more than have their early intervention services once out of several presentations provider assist them in doing the ELF at 6 feet would the parent mark the listening activities and observing the response as a ‘maybe.’ child’s behavior. The ELF responses should be shared with the early inter- A radio set on a talk station or the vention team to enhance the child’s television on in the background program. Also, discuss with the par- would be appropriate when present- ents if they or you will be expected to ing listening activities in noise. Try to complete one or both of the ELF score have this background noise on in the sheets. Not all families, audiologists, same room or an adjoining room with or early interventionists will want to the door open when presenting the track performance over time. There- listening activities. The point is to see fore, the audiologist needs to tailor if the child who responds in quiet can ELF score sheet use for the individual also respond when noise is present. familiy.

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

The signal to noise ratio is expected • Saying ‚sss-shh, sss-shh, sss-shh‘ to be typical for the home, rather than rather than‚ shoe-buh‘ in number 9. a calibrated stimulus. Responses to the ELF listening activities will be In discussing the activities with the most pronounced for children who parents, if the parents do not feel have a fl at confi guration of hearing comfortable with any of the listen- loss or at least a mild degree of hearing activities, discuss with them ing loss across all speech frequencies. what a suitable replacement activity with quiet, typical, loud, or high or Children who have normal hearing low frequency characteristics might through the low frequencies may be from their own environment. have robust responses to most or all The activities should be easy to do of the listed ELF listening activities. and easy to repeat over time. For an The audiologist or early intervention- example of rough use of frequency ist working with the parents must range, ‘buh buh buh’ is considered a be aware of this potential and may lower frequency speech stimulus and choose to not use the ELF if there is ‘ship ship ship’ a higher frequency an island of normal or minimal hear- speech stimulus.The phrase ‘shoe- ing loss. Alternatively, the audiolo- ba, shoe-ba, shoe-ba’ is considered gist or early interventionist may work to have both low and high frequency with the family to include or replace elements. some of the existing items with high frequency listening activities such as: Caution the parents to hit the frying pan or do a loud door knock from • Quiet ‚tsk, tsk, tsk‘ sound in number a distance fi rst. These loud sounds 3 rather than quiet clucking tongue should be presented close to the baby’s head only when more distant • Mommy saing ‚sss, sss, sss‘ responses were not observed, espe- quietly in number 4 rather than cially when amplifi cation is worn. Take ‚buh, buh, buh‘ the time to warn the parents about the dangers of loud sounds on hearing • Contrasting a child’s responses to and comfort. a caregiver making the sound of a duck quacking with the sound of a Expected Responses snake hissing rather than clapping Young children respond best to voices, hands together in number 7 (only especially the voices of their par- record response for hissing sound). ents. Developmentally, newborns and children with normal hearing who are • Response to shh-shh, shh-shh under 5 months of age do not respond rather than „ship ship ship“ in to very low intensity sounds. number 8.

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

The quiet listening activities listed Infants older than 6 months will have may produce no response beyond clearer responses to sound and the six inches or three feet, especially if use of the ELF listening activities by the a moderate hearing loss or greater is parents may be more successful then. present. For children with normal hearing, ru- Reassure the parents to not be con- dimentary headturns can be expected cerned about these quiet activities un- at a developmental age of 5 months, til the child is at least 4–5 months old. only on a lateral plane, and a listen- Reinforce that the baby needs to be ing attitude may be present, includ- quiet and content. Even when in the ing more interest in quiet voices. most receptive state, a baby may only Developmentally, at 7-9 months the respond once or twice to the listening baby begins to be highly responsive activity. It is expected that the ELF will to quiet voices and may localize to take a concerted eff ort over a period of the side and indirectly below to either days to complete. If there is an audi- side. At 9-13 months of age to either ology appointment scheduled in two side localization includes indirectly weeks, urge the parents to complete above. At 13-16 months developmen- as much of it as possible. Their level tal age and beyond, localization to of participation can provide insights the sides, below, and above is an into their state of grieving or real life expected response. priorities in the family. The ELF is just one of the many tools Model for the parent or describe and techniques available to elicit what to look for in the young infant’s impressions about a young child’s responses. The following responses hearing ability. It is not intended are some of the easier behaviors to to be a diagnostic tool or a formal observe: screening measure to detect hearing impairment or replace appropriate 1) Moro response or startle reaction Real-Ear-to-Coupler Diff erence ampli- resulting in a full body jerk, fi cation verifi cation techniques. The ELF is intended to involve the parents 2) cessation of activity, stopping or caregivers of a child with identifi ed movement, cessation of sucking, hearing loss in gathering information quieting of random or intentional on how the young child is able to movements, use his or her hearing ability under contrived listening situations in their 3) starting to suck or initation of limb environment. movements if the infant had been relatively still.

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

ELF – Early Listening Function

Discovery tool for parents and caregivers of infants and toddlers

Why? are using your hearing range. In other Hearing is a distance sense and a words, you have a listening bubble child with a hearing loss will have a that includes hearing sounds of that reduced hearing range, or a smaller loudness and at that distance. People listening bubble, than a child with with hearing loss have smaller listen- normal hearing. When you hear your ing bubbles. How well young children young child fuss in the crib or bed with hearing loss function varies when you are in another room, you between individuals and typically

Mooo Mooo The size of a child’s listening bubble is based on his or her degree of hearing loss and consistent, daily use of ampliﬁ cation.

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

shows some improvement with listen- Who? ing experience. Audiologists test With another adult, try the following to fi nd out what tones or pitches of activities with your child. Infants or sound (from low to high) a child can young children may react to a new detect. Only someone who is with the sound only once, so you will need to child for hours everyday can observe try these diff erent activities over a how the child is using his/her hearing number of days. At least one adult, ability in every day situations. Babies like mom or the daily caregiver, can react to sounds even while in should be doing all of these activi- the womb, so no child is too young ties with the child. The helper can be to observe for responses to sound. dad, the early intervention teacher, Hearing aids will improve the size grandma, a neighbor, etc. Two activi- of the listening bubble. With use of ties ask for mom and dad’s voice. If it amplifi cation during all waking hours, is not possible for a parent to do this, auditory skills will usually improve a female and male voice should be over time, including how well a child used. If there is no male voice avail- is able to use sound for speech and able, a female voice can be used, but verbal language. the pitch of the voice used should be very low.The purpose is to fi nd out if your child responds better to lower or higher pitch sounds.

Buh buh buh

The size of a child’s listening bubble is based on his or her degree of hearing loss and consistent, daily use of ampliﬁ cation.

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

What? When? As you watch your child’s reaction to All activities should be tried when the sound, a response may be obvious, baby is settled – awake but quietly like startling or jerking the whole sucking on a bottle, alert and looking body when a louder sound is present, at something interesting or playing or very subtle. For young infants, a with soft, quiet toys. A fussy baby, a change in breathing speed, sucking toddler on the run, or a young child on a bottle and stopping when who is sleeping, is not ready to re- the sound occurs, eye widening or spond to sounds. You know your child blinking, stopping all movement, best! You are more aware than any- movements of the arms or legs at the one else of when your child responds onset of the sound, or small frowns best to things going on around him can all be subtle signs that a 1-4 or her. Take 5 minutes when the baby month old baby heard a sound. The seems most responsive to try some baby may do this only once or twice of these listening activities. There are and then, even if the sound is heard, many diff erent listening situations will probably not respond again for that we are exposed to everyday. It is awhile. Young children respond best important to determine your child’s to voices. They do not respond to ability to respond to sounds under quiet sounds as well as older infants quiet and noisy listening conditions. as this skill develops with listening What is meant by quiet is having the experience. Due to this, an infant television, music, or radio off , picking may seem to have more hearing loss a time when any other children in the at fi rst than he really does. This is house are doing quiet activities in why it is important to remember that another part of the living area. Look the ELF activities are meant to look at for short, calm periods over time in functional responses to sound. Start- which to administer the quiet activi- ing at about 5 months, the child may ties. Noise refers to the typical busy purposefully turn in the direction of a household activities, such as when sound, looking for the sound source. the TV is on or children are playing. People need two ears with the same level of hearing to localize sound. If the child does not look for sounds as you would expect, there maybe diff erent hearing ability in each ear.

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

How? reacting to sound, and didn’t just The activities were developed with a happen to move for any of a number typical household in mind. You will of reasons other than noticing the be trying to get an idea of how your sound you just made. Babies in their child will respond to sound at each fi rst couple of months can seem com- distance, at fi rst in quiet. Then intro- pletely unaware to sound, even when duce activities in noise. Start with the they have some hearing. Children sounds at 6 inches, beginning with with hearing loss are often very aware the quietest sound and then intro- of other sensory input such as visual ducing the typical loudness sounds. (movements/motion) or tactile If you know your baby responds (vibrations/feeling). When you are readily to an activity at a quiet or doing the listening activities you typical loudness, assume that he or need to be sure that you are behind she will also respond when the loud the child so that your baby cannot activity is presented at that distance. see you. Be sure your shadow is not Loud sounds can cause discomfort visible or your breath or other vibra- or an adverse response. In some tions are not felt by the child, causing circumstances, loud sounds espe- a reaction, rather than the response cially for long periods over time may being a specifi c auditory response. actually damage hearing. Therefore, Doing the listening activities within introduce the loud sounds at 15 and six inches to three feet of your child 10 feet fi rst. Do not produce a loud will be the trickiest! Try to be consist- sound (hitting a frying pan) close ent about how loud you make the to your young child unless you see noises as you present them at diff er- no response to the quieter listening ent distances. Your opinion based on activities or no response to the loud watching your child respond to sound sounds at the farthest distances. is important! You will need to try to get two or more reactions to sound for each activity to be sure that the child was actually

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

ELF – Early Listening Function

Discovery tool for parents and caregivers of infants and toddlers

Child’s name:

Child’s birthdate:

Observer(s):

Place(s)

Date(s) of ELF observations: 1 3

You will be watching how your child Loud sounds can cause adverse respons- responds to 12 listening activities you es or discomfort. In extreme cases, a very will present in your home or wherever the loud sound could harm hearing. There- child is much of his or her waking hours. fore, it is important to not present the loud sounds close to your baby unless you have observed no responses to quieter sounds at near distances. Watch 2 for responses in noise only after responses in quiet have been observed. Children who are alert, but not fussy are in the best state to respond to sound. These responses can be very subtle. Most of the time the child will only 4 respond once or twice to the sound and then will not pay attention again The favorite and most interesting sound for awhile. It may take observing your for a baby is the voice of the parents child over the course of a week before or daily caregivers. Finding out how you have presented the sounds enough well your voice is heard by the baby is times to feel fairly certain about your important to know for encouraging the child’s capability to respond. development of auditory and verbal communication skills.

Written by Karen Anderson, 2002. Design by Oticon, 2007 5 7

Even babies with normal hearing who are Put a Y in the box, meaning YES, if you have less than 5 months of age do not respond observed the child responding to the specifi ed to quiet sounds. Instead, they tend to listening activities most of the time (e.g., 4 of startle at loud noises and may or may not 5 times). Put an M in the box, meaning MAYBE, respond to sounds at typical loudness. If if you have observed the child responding to you do not observe a response to sound, some sounds, but only about half of the time keep observing the child as his or her au- (e.g., 2 or 3 of 5 times). Put an N in the box, ditory system develops. The ELF listening meaning NO, if you have observed no sure re- activities will be easiest for babies to sponses to the listening activity. respond to if they are at least a developmental age of 5 months. 8 6 If you know your child responds to the quiet sounds, put a Y in the box for the louder For most children with hearing loss who sounds. If he or she responded to the distant are listening in a quiet setting there will be sounds for an activity, assume the child will no response to the quiet sounds or distant respond to those sounds when near. If you listening activities, especially when no am- know your child was unable to respond to plifi cation is used. Even children with mild the loud sounds, put an N in the box for the or unilateral hearing loss will have some quieter sounds. If the child did not respond to limitations listening to distant sounds or in near sounds, assume that he or she will not noise. When the typical loudness sounds respond to far sounds. are presented close, it is anticipated that a child with a mild or moderate hearing loss will respond. The child may have inconsist- ent responses to the distant sounds when no amplifi cation is used, and may respond to some quiet sounds with working amplifi cation. Children who have a severe or profound degree of hearing loss may have few responses, even to the loud sounds.

Written by Karen Anderson, 2002. Design by Oticon, 2007 Listening Activities Sheet > Parents Response Form

Based on the child’s responses Listening activities at diﬀ erent distances to sound, place Y (Yes), M Closest distance (Maybe) or N (No) in the boxes Next child responded below room in noise 6 ins. 3 ft.6 ft. 10 ft. (15+feet) (none, > 6 ft)

1. Mommy saying “sh,sh”quietly

2. Hands together, palms rubbing

together briskly

3. Quiet clucking tongue Quiet Activities 4. Mommy saying ‘buh buh buh’ quietly

5. Turning water full on (kitchen sink, bathtub) 6. Mommy singing a song (i.e., Mary had a Little Lamb) 7. Clapping hands together in quiet applause 8. Daddy saying ‘ship ship ship’ in

Typical Loudness Activities Loudness Typical normal voice loudness

9. Daddy says ‘shoe-buh, shoe- buh’ in loud voice

10. Loud door knock with knuckles 11. Hold 2 spoons together back-to- back by their ends and hit them Loud Activities Loud hard on your palm twice 12. Hitting a frying pan or pot with a wooden or metal spoon

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

ELF – Checklist > Parents Response Form

Infant & Young Child Ampliﬁ cation Use Checklist

Child’s name:

Child’s birthdate:

Date completed:

Parents please complete this form each time your child uses new hearing aids, hearing aid settings, features, programs or other amplifi cation devices, like FM systems or a cochlear implant map. Amplifi cation devices are set precisely, however, some minor adjustments may be needed for optimal listening ability. Your observations can assist in determining improvements how well this amplifi cation is meeting your child’s listening needs in his or her every day environ- ments. Complete these items approximately 4 to 10 days after your child begins to listen with the new or newly adjusted amplifi cation. If possible, ask your child’s other caregivers and the early intervention specialist that works with your family about what changes they observe. Share the completed form with the audiologist and be sure to discuss any questions you may have about the child’s hearing or use of the amplifi cation instrument.

Describe current ampliﬁ cation used (new settings, etc.):

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

A listening check of the ampliﬁ cation instruments is typically performed by an adult______times per (day) or (week) (e.g., battery check, listening with stethoset, watching for child responses to m, aw, oo, ee, sh, s, t sounds, checking settings, earmold ﬁ t, etc.)

Are parents/caregivers comfortable using the ampliﬁ cation system?

(very) (mostly) (somewhat) (not really) (no)

Are parents/caregivers comfortable with how to check and maintain?

(very) (mostly) (somewhat) (not really) (no)

On a typical day, my child wears ampliﬁ cation______hours out of approximately______waking hours

Describe speciﬁ c situations when you noticed improvements in listening ability:

Not Observed

Disagree No change Agree

My child appears to:

1. Be more aware of my voice (-2) (-1) (0) (1) (2)

2. Be more aware of environmental sounds (-2) (-1) (0) (1) (2)

3. Search more readily for the location of my voice (-2) (-1) (0) (1) (2)

4. Have an increased amount of babbling or talking (-2) (-1) (0) (1) (2)

5. Have more interest in communicating (-2) (-1) (0) (1) (2)

During ELF listening activities, the size of my child’s listening bubble:

1. Has improved for quiet sounds voices (-2) (-1) (0) (1) (2)

2. Has improved for typical sounds and voices (-2) (-1) (0) (1) (2)

3. Has improved for loud sounds and voices (-2) (-1) (0) (1) (2)

4. Has improved for listening in background noise (-2) (-1) (0) (1) (2)

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

ELF – Score Sheet > Professional Response Form

Child’s name:

Child’s birthdate:

Date completed:

Audiologist or Early Interventionist: If desired, a child’s observed responses to ELF listening activities can be converted to a numeric form and compared across time as the child develops auditory skills, experiences fl uctuating hearing, or is fi t with amplifi cation instruments.

Count and multiply responses on the ELF parent response form to obtain weighted scores for quiet listening and bonus listening in noise points.

Listening in Quiet: Count the number of Y’s and M’s for each distance. If both are present only transfer the number of Y’s.

Listening in Noise: Transfer the amount of responses where the child responded at a distance > 6 ft.

Step 1: Transfer numbers from Parent Response Form

Step 2: Multiply by weight factor

Written by Karen Anderson, 2002. Design by Oticon, 2007 ELF - Early Listening Function

Date(s)

Listening in Quiet (Y = Yes / M = Maybe)

Quiet Typical Loud TOTAL (100 possible)

No. of Multiply No. of Multiply No. of Multiply No. of Multiply No. of Multiply No. of Multiply Add Yes x 10 Maybe x 8 Yes x 7 Maybe x 5 Yes x 3 Maybe x 1 multiplied numbers

6 Ins.

3 Ft.

6 Ft.

10 Ft.

Next room

Listening in Noise

Quiet Typical Loud Total noise bonus points Responses noted Responses noted Responses noted (200 possible)

> 6 feet Multiply x 25 > 6 feet Multiply x 15 > 6 feet Multiply x 10 Add multiplied numbers

Hearing Status

* New diagnosis, new ampliﬁ cation, parent detected possible ear infection, check auditory development, etc.

Written by Karen Anderson, 2002. Design by Oticon, 2007 Hearing Loss Management Considerations Discussed by audiologist/interventionist:

Date(s)

Size of listening bubble (proximity for communication) in quiet needs to be at______distance or closer when no ampliﬁ cation is used.

Size of the listening bubble (proximity for communication) in quiet needs to be at______distance or closer when ampliﬁ cation is worn consistently.

Control of background noise needed when communicating, especially when distance between baby and speaker is beyond______feet.

Trial of hearing aid(s): type or special features.

Trial or continued use of hearing aid(s): type or special features.

Improvement noted due to early auditory development or progress in auditory skills.

Potential cochlear implant user, suggest parents contact implant team for more information.

Potential user for an FM system, due to diﬃ culties listening in noise and to speech at a distance. Parent or caregiver has demonstrated willingness to use FM during the child’s waking hours.

Hours use throughout the day: ______

Other:

Written by Karen Anderson, 2002. Design by Oticon, 2007 www.oticon.ca www.oticonusa.com solutions. loss ﬁ hearing with people of andwishes needs individual the put we why That’s instruments. hearing best the tocreate andaudiology technology than People First rst in our development of new hearing care care hearing new of development inour rst We believe that it takes more more takes it that We believe

910 15 911 00/09.07 Printed in Denmark