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charscalex100 \ul0\nosupersub\cf5\f6\fs18 John M.A. Oyiborhoro, Ed.D., F.A.A.A.,
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ar\pard\li1551\sb10\sl-230\slmult0\fi199\tx7493 \up0 \expndtw-9\charscalex95 Rel
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entity\tab \up0 \expndtw-9\charscalex95 298\par\pard\li1551\sb8\sl-230\slmult0\f
i199\tx7481 \up0 \expndtw-9\charscalex95 Chronologic/Developmental Challenges\ta
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harscalex95 302\par\pard\li1551\sb9\sl-230\slmult0\fi199\tx7491 \up0 \expndtw-9\
charscalex95 Family History and Inuence\tab \up0 \expndtw-9\charscalex95 303\par\
pard\li1551\sb9\sl-230\slmult0\fi199\tx7483 \up0 \expndtw-9\charscalex95 Unique
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10\sl-230\slmult0\fi199\tx7489 \up0 \expndtw-9\charscalex95 Location of Residenc
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\tab \up0 \expndtw-9\charscalex95 316

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ns begin. \par\pard\qj \li1286\ri960\sb210\sl-260\slmult0 \up0 \expndtw-5\charsc
alex100 \ul0\nosupersub\cf2\f3\fs22 Brenda Y. Cartwright, Ed.D., CRC, LPC (
287), Department of \line \up0 \expndtw-9\charscalex100 Counselor Education, U
niversity of Hawaii at Manoa, Honolulu, HA \par\pard\qj \li1286\ri961\sb160\sl-2
60\slmult0 \up0 \expndtw-2\charscalex100 Mary Jean J. Dyczko, M.A., CCC/SLP, TSH
H, ATP (210), NYS \up0 \expndtw-10\charscalex95 Licensed Speech-Language Path
ologist, RESNA Certied Assistive \up0 \expndtw-8\charscalex100 Technology Pra
ctitioner, Practicing Augmentative and Alternative \up0 \expndtw-10\charscal
ex97 Communication Specialist, New York, NY \par\pard\qj \li1286\ri962\sb160\sl260\slmult0 \up0 \expndtw-7\charscalex100 Cindy Gustin, PH, MSc (79), St. Paul\u
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uver, British \up0 \expndtw-9\charscalex100 Columbia \par\pard\qj \li1286\ri961\
sb160\sl-260\slmult0 \up0 \expndtw-8\charscalex100 Emi Isaki, Ph.D., CCC/SLP (11
8), Division of Speech Pathology and \up0 \expndtw-9\charscalex100 Audiology, Jo
hn A. Burns School of Medicine, University of Hawaii at \up0 \expndtw-9\charscal
ex100 Manoa, Honolulu, HA \par\pard\qj \li1286\ri961\sb160\sl-260\slmult0 \up0 \
expndtw-6\charscalex100 Nancy Lenhart Jones, M.S., CCC/SLP, TSHH, ATP (210)
, NYS \up0 \expndtw-10\charscalex95 Licensed Speech-Language Pathologist, RES
NA Certied Assistive \up0 \expndtw-8\charscalex100 Technology Practitioner, P
racticing Augmentative and Alternative \up0 \expndtw-10\charscalex97 Communic
ation Specialist, New York, NY \par\pard\ql \li1286\sb166\sl-253\slmult0 \up0 \e
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, Alton, IL \par\pard\qj \li1286\ri960\sb142\sl-260\slmult0 \up0 \expndtw-3\char
scalex100 John M.A. Oyiborhoro, Ed.D., F.A.A.A., CCC-A (1, 26, 59, 154), \up0 \
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for People \up0 \expndtw-7\charscalex100 with Disabilities, New York, NY \par\pa
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r K. Parthasarathy, Ph.D. (134), Department of Special \up0 \expndtw-9\ch
arscalex100 Education and Communication Disorders, Southern Illinois University
\up0 \expndtw-10\charscalex95 Edwardsville, Edwardsville, IL \par\pard\qj \li128
6\ri961\sb160\sl-260\slmult0 \up0 \expndtw-8\charscalex100 Kenneth C. Pugh, P
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3 \ul0\nosupersub\cf1\f2\fs28 FOREWORD \par\pard\qj \li1286\sb0\sl-280\slmult0 \
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lt0 \up0 \expndtw-9\charscalex96 \ul0\nosupersub\cf2\f3\fs22 During the 1940s
audiology was established by its founders as a \line \up0 \expndtw-9\cha
rscalex94 profession that provided aural rehabilitation for GIs newly de
afened \line \up0 \expndtw-10\charscalex96 in World War II. From this important
beginning, audiology experienced \line \up0 \expndtw-8\charscalex100 a broad e
xpansion of its scope of practice from identication of \line \up0 \expndt
w-10\charscalex97 hearing loss in the newborn to diagnostic assessment of site o
f lesion \line \up0 \expndtw-6\charscalex100 in the auditory system. At this tim
e many audiologists provide aural \line \up0 \expndtw-9\charscalex98 rehabilitat
ion to children and adults in pediatric settings, schools, \line \up0 \e
xpndtw-10\charscalex96 community clinics, dispensing audiology practices, and ot
her venues. \line \up0 \expndtw-9\charscalex98 Nevertheless, in many ways a
ural rehabilitation has not received \line \up0 \expndtw-9\charscalex94 the
focus of professional attention that is deserved by the persons \line
\up0 \expndtw-10\charscalex88 we serve. \par\pard\qj \li1286\ri960\sb243\sl-277\
slmult0\fi478 \up0 \expndtw-10\charscalex95 This timely book takes us back to ou
r roots and reminds us about \up0 \expndtw-9\charscalex96 the importance and pla
ce of aural rehabilitation for persons with a wide \up0 \expndtw-9\charscalex100
range of disabilities. Dr. Oyiborhoro has assembled a panel of knowl\up0 \expnd
tw-10\charscalex89 edgeable authors to explore the problems of assessment and ma
nagement \up0 \expndtw-9\charscalex94 of individuals with unique and someti
mes devastating diseases. The \up0 \expndtw-9\charscalex93 topics include se
veral areas of discussion including amplication and \up0 \expndtw-10\charscal
ex94 assistive technology, augmentative and alternative communication, and \up0
\expndtw-10\charscalex95 the important area of counseling. \par\pard\qj \li1286\
ri961\sb241\sl-280\slmult0\fi478 \up0 \expndtw-10\charscalex95 Readers of this b
ook will nd the information to be helpful as they \up0 \expndtw-9\charscalex94 pr
ovide services to people with disabilities. The information is applicable \up0 \
expndtw-9\charscalex94 to a wide range of readers from students to exper
ienced practicing \up0 \expndtw-10\charscalex96 audiologists. Speech-language p
athologists and others who work with \up0 \expndtw-9\charscalex97 hearing-impair
ed persons who have other disabilities will also nd this \up0 \expndtw-10\charsca
lex94 book to be an important resource. \par\pard\ql \li4292\sb0\sl-207\slmult0
\par\pard\ql\li4292\sb0\sl-207\slmult0 \par\pard\ql\li4292\sb0\sl-207\slmult0 \p
ar\pard\ql\li4292\sb0\sl-207\slmult0 \par\pard\ql\li4292\sb0\sl-207\slmult0 \par
\pard\ql\li4292\sb66\sl-207\slmult0 \up0 \expndtw0\charscalex111 \ul0\nosupersub
\cf5\f6\fs18 xv \par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240
{\bkmkstart Pg18}{\bkmkend Pg18}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1
551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx4471 \up0 \exp
ndtw-4\charscalex100 \ul0\nosupersub\cf2\f3\fs22 xvi\tab \up0 \expndtw-4\charsca
lex100 \ul0\nosupersub\cf5\f6\fs18 Foreword\par\pard\qj \li1551\sb0\sl-280\slmul
t0 \par\pard\qj\li1551\ri697\sb53\sl-280\slmult0\fi478 \up0 \expndtw-9\charscale
x100 \ul0\nosupersub\cf2\f3\fs22 I congratulate Dr. Oyiborhoro for his eort
s in bringing this \up0 \expndtw-7\charscalex100 important project to fruitio
n. I am sure that the readers will join me in \up0 \expndtw-10\charscalex95 thei
r appreciation of the information provided here. \par\pard\qj \li5752\sb0\sl-280
\slmult0 \par\pard\qj\li5752\ri696\sb201\sl-280\slmult0 \up0 \expndtw-10\charsca
lex95 Robert W. Keith, Ph.D. \line \up0 \expndtw-10\charscalex92 Professor and D
irector \par\pard\ql \li3891\ri695\sb1\sl-280\slmult0\tx4269 \up0 \expndtw-10\ch
arscalex95 Division of Audiology and Vestibular Testing \line\tab \up0 \expndtw10\charscalex96 University of Cincinnati Medical Center \par\pard\ql \li5803\sb2
3\sl-253\slmult0 \up0 \expndtw-7\charscalex100 Cincinnati, Ohio USA \par\pard\ql
\li6672\sb247\sl-253\slmult0 \up0 \expndtw-10\charscalex88 July 21, 2004
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz30\shplid0

{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{

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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
19}{\bkmkend Pg19}\par\pard\ql \li2810\sb0\sl-322\slmult0 \par\pard\ql\li2810\sb
0\sl-322\slmult0 \par\pard\ql\li2810\sb0\sl-322\slmult0 \par\pard\ql\li2810\sb0\
sl-322\slmult0 \par\pard\ql\li2810\sb0\sl-322\slmult0 \par\pard\ql\li2810\sb264\
sl-322\slmult0 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf1\f2\fs28 ACKNOWLE
DGMENTS \par\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\sb0\sl-260\s
lmult0 \par\pard\qj\li1286\ri960\sb50\sl-260\slmult0 \up0 \expndtw-9\charscalex1
00 \ul0\nosupersub\cf2\f3\fs22 The impetus for writing this book was provided wh
ile working with the \line \up0 \expndtw-10\charscalex93 wonderful consumers (pe
ople with special needs) at the United Cerebral \line \up0 \expndtw-4\charscalex
100 Palsy of New York City, Inc.; the National Institute for People with \line \
up0 \expndtw-9\charscalex96 Disabilities, also known as YAI; Heartshare We
llness; the Hebrew \line \up0 \expndtw-7\charscalex100 Academy for Special Chi
ldren (HASC); and Bais Ezra in New York. \line \up0 \expndtw-7\charscalex100 I
am grateful to the consumers, their parents, their signicant others, \line \up0 \
expndtw-9\charscalex93 and their direct caregivers for teaching me so much about
patience, love, \line \up0 \expndtw-10\charscalex95 endurance, wisdom, and appr
eciation for human life. I thank my collea-\line \up0 \expndtw-7\charscalex100 g
ues at the United Cerebral Palsy of New York City, Inc., especially \line \up0 \
expndtw-10\charscalex95 David Gross, AnthonyAversano, and Mrs. Miriam Pratt for
their support \line \up0 \expndtw-10\charscalex93 and friendship. \par\pard\qj \
li1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 My special
thanks to my teachers at Teachers College, \line \up0 \expndtw-4\c
harscalex100 Columbia University in New York City and at Case Western \
line \up0 \expndtw-7\charscalex100 Reserve University in Cleveland, Ohio, e
specially Drs. Barbara \line \up0 \expndtw-10\charscalex94 Weinstein, Craig Ne
wman, Hugh Catts, and Celia Hooper. I am grateful \line \up0 \expndtw-9\charscal
ex96 to Mrs.ValentaWard-Gravely for imparting her incisive clinical skills and \
line \up0 \expndtw-10\charscalex96 to Professor James Nation and Drs. Dani
elle Ripich and Alex \par\pard\qj \li1286\ri959\sb0\sl-260\slmult0 \up0 \expn
dtw-9\charscalex100 F. Johnson for their understanding and support. Also, I than
k Donald \line \up0 \expndtw-9\charscalex100 and Debbie Robin for the share
d and rewarding experiences at \line \up0 \expndtw-10\charscalex92 Case West
ern Reserve University. The assistance of my former students \line \up0 \expndtw
-8\charscalex100 at Pace University in New York City in the initial literature s
earch and \line \up0 \expndtw-7\charscalex100 references is appreciated. My than
ks to Dr. Dorothy Ogundu for her \line \up0 \expndtw-9\charscalex100 constant re
minders and encouragement to complete the book, and to \line \up0 \expndtw-10\ch
arscalex94 Drs. George Mencher and Ross J. Roeser for their interest and support
. \line \up0 \expndtw-5\charscalex100 I wish to thank Rebecca Ann Conrow, Ari Ab
reau, Genni Arreaga, \line \up0 \expndtw-10\charscalex96 Adriana Rua, and Lola P
earson for their help. My special thanks to my \line \up0 \expndtw-10\charscalex
95 family for their support and encouragement. I also extend my thanks to \line
\up0 \expndtw-9\charscalex92 the former and present sta of Academic Press, especi
ally Mark Zadrozny \line \up0 \expndtw-9\charscalex94 for the initial contacts a
nd Mara Conner for her patience, understanding, \line \up0 \expndtw-10\charscale
x94 and encouragement in completing the book. \par\pard\ql \li5481\sb246\sl-253\
slmult0 \up0 \expndtw-7\charscalex100 John M.A. Oyiborhoro \par\pard\ql \li4236\
sb0\sl-207\slmult0 \par\pard\ql\li4236\sb58\sl-207\slmult0 \up0 \expndtw0\charsc
alex119 \ul0\nosupersub\cf5\f6\fs18 xvii \par\pard\sect\sectd\fs24\paperw8700\pa
perh13020\pard\sb0\sl-240{\bkmkstart Pg20}{\bkmkend Pg20}\pard\par\pard\sect\sec
td\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg21}{\bkmkend Pg21}\p

ar\pard\ql \li3345\sb0\sl-368\slmult0 \par\pard\ql\li3345\sb0\sl-368\slmult0 \pa

r\pard\ql\li3345\sb0\sl-368\slmult0 \par\pard\ql\li3345\sb212\sl-368\slmult0 \up
0 \expndtw0\charscalex113 \ul0\nosupersub\cf12\f13\fs32 CHAPTER 1 \par\pard\ql \
li2864\sb0\sl-368\slmult0 \par\pard\ql\li2864\sb324\sl-368\slmult0 \up0 \expndtw
0\charscalex90 \ul0\nosupersub\cf13\f14\fs32 Overview of Disabilities \par\pard\
ql \li2050\sb0\sl-253\slmult0 \par\pard\ql\li2050\sb74\sl-253\slmult0 \up0 \expn
dtw0\charscalex100 \ul0\nosupersub\cf14\f15\fs22 John M.A. Oyiborhoro, Ed.D., F.
A.A.A., CCC-A \par\pard\ql \li3471\ri3176\sb0\sl-240\slmult0\tx3804 \up0 \expndt
w-4\charscalex100 \ul0\nosupersub\cf15\f16\fs20 Boro Audiology Clinic \line\tab
\up0 \expndtw-4\charscalex100 Brooklyn, NY \par\pard\ql \li4250\sb7\sl-230\slmul
t0 \up0 \expndtw-9\charscalex92 and \par\pard\ql \li2581\sb10\sl-230\slmult0 \up
0 \expndtw-8\charscalex100 National Institute for People with Disabilities \par\
pard\ql \li3780\sb10\sl-230\slmult0 \up0 \expndtw-4\charscalex100 New York, NY \
par\pard\ql \li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb60\sl-230\slmult0 \
up0 \expndtw0\charscalex101 Concept of Disability \par\pard\qj \li2840\ri2345\sb
2\sl-240\slmult0 \up0 \expndtw-3\charscalex100 Consequences of Hearing Impairmen
t \up0 \expndtw-3\charscalex100 Mental Retardation \par\pard\ql \li2840\ri4034\s
b0\sl-240\slmult0 \up0 \expndtw-3\charscalex100 Down\ul0\nosupersub\cf16\f17\fs2
0 \u8217?\ul0\nosupersub\cf15\f16\fs20 s Syndrome \line \up0 \expndtw-6\charscal
ex100 Cerebral Palsy \line \up0 \expndtw-6\charscalex100 HIV/AIDS \par\pard\qj \
li2840\ri3929\sb0\sl-240\slmult0 \up0 \expndtw0\charscalex102 Visual Impairment
\line \up0 \expndtw-5\charscalex100 Sociocultural Issues \par\pard\ql \li2840\ri
2148\sb0\sl-240\slmult0 \up0 \expndtw-2\charscalex100 Management of People with
Disabilities \up0 \expndtw-1\charscalex100 People with Other Disabilities \line
\up0 \expndtw-8\charscalex100 References \par\pard\ql \li2840\sb9\sl-230\slmult0
\up0 \expndtw-7\charscalex100 Selected Readings \par\pard\qj \li1286\sb0\sl-258
\slmult0 \par\pard\qj\li1286\ri959\sb9\sl-258\slmult0\fi478 \up0 \expndtw-10\cha
rscalex95 \ul0\nosupersub\cf14\f15\fs22 The Americans with Disabilities Act was
enacted into law in 1990. \line \up0 \expndtw-10\charscalex97 The law required t
hat equal opportunities be created by employers for \line \up0 \expndtw-3\charsc
alex100 individuals with any form of disability. Any form of discrimination, \li
ne \up0 \expndtw-9\charscalex100 especially in employment, was prohibited by the
new law. Since then \line \up0 \expndtw-10\charscalex92 signicant changes have b
een made in places of employment, entertain-\line \up0 \expndtw-10\charscalex95
ment, and education to actualize this new law of inclusion. To enhance \line \up
0 \expndtw-9\charscalex92 communication, public facilities, where necessary, are
required to provide \line \up0 \expndtw-9\charscalex98 auxiliary devices for in
dividuals with hearing, vision, or speech impair-\line \up0 \expndtw-9\charscale
x94 ments. Auxiliary devices include assistive listening devices, televisio
n \line \up0 \expndtw-10\charscalex97 captioning and decoders, telecommunicat
ion devices for the deaf \line \up0 \expndtw-8\charscalex100 (TDD), video te
xt displays, reader taped texts, and brailled materials \line \up0 \expndtw-10\c
harscalex91 as well as large-print materials. \par\pard\ql \li4353\sb0\sl-207\sl
mult0 \par\pard\ql\li4353\sb78\sl-207\slmult0 \up0 \expndtw-2\charscalex100 \ul0
\nosupersub\cf17\f18\fs18 1 \par\pard\qj \li3067\ri2882\sb0\sl-160\slmult0\fi65
\up0 \expndtw0\charscalex100 \ul0\nosupersub\cf18\f19\fs12 Aural Rehabilitation
for People with Disabilities \line \up0 \expndtw0\charscalex100 Copyright \up0 \
expndtw-2\charscalex100 2005, Elsevier Inc. All rights reserved.
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\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx3030 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf14\f15\fs22 2\tab \up0 \expndtw-8\charscalex97 \ul0\nos
upersub\cf17\f18\fs18 Aural Rehabilitation of People with Disabilities\par\pard\
qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri695\sb70\sl-260\slmult0\fi47
8 \up0 \expndtw-10\charscalex97 \ul0\nosupersub\cf14\f15\fs22 The Developmental
Disabilities Assistance and Bill of Rights Act \up0 \expndtw-9\charscalex93 of 1
990 dened developmental disability as a severe, chronic disability of \up0 \expnd
tw-10\charscalex93 an individual 5 years of age or older that is \par\pard\qj \l
i2030\sb0\sl-260\slmult0 \par\pard\qj\li2030\ri697\sb120\sl-260\slmult0\tx2276 \
up0 \expndtw-10\charscalex93 1. attributable to a mental or physical impairment
or a combination \line\tab \up0 \expndtw-10\charscalex94 of both; \par\pard\ql
\li2030\sb6\sl-253\slmult0 \up0 \expndtw-10\charscalex92 2. manifested before t
he individual attains age 22; \par\pard\ql \li2030\sb7\sl-253\slmult0 \up0 \expn
dtw-10\charscalex96 3. likely to continue indenitely; and \par\pard\ql \li2030\r
i694\sb0\sl-262\slmult0\tx2285\tx2285\tx2285\tx2285\tx2285\tx2285\tx2285\tx2285
\up0 \expndtw-7\charscalex100 4. likely to result in substantial functional lim
itations in three or \line\tab \up0 \expndtw-10\charscalex94 more of the followi
ng areas of major life activity such as (i) self-\line \tab \up0 \expndtw-10\cha
rscalex82 care, \up0 \expndtw-10\charscalex95 (ii) receptive and expressive lang
uage, (iii) learning, (iv) \line \tab \up0 \expndtw-9\charscalex100 mobility,
(v) self-direction, (vi) capacity for independent living, \line \tab \up0 \expnd
tw-9\charscalex100 (vii) economic self-su\u8260?ciency, and (viii) demonstration
of\ul0\nosupersub\cf19\f20\fs22 \u8216?\u8216?\ul0\nosupersub\cf14\f15\fs22 t
he \line \tab \up0 \expndtw-10\charscalex91 individual\ul0\nosupersub\cf19\f20\f
s22 \u8217?\ul0\nosupersub\cf14\f15\fs22 s need for a combination and sequ
ence of special \line \tab \up0 \expndtw-10\charscalex92 interdisciplinary or
genetic services, support, or other assistance \line \tab \up0 \expndtw-7\charsc
alex100 that are of lifelong or extended duration and are individually \line \ta
b \up0 \expndtw-10\charscalex91 planned and coordinated. . . \up0 \expndtw-10\ch
arscalex82 .\ul0\nosupersub\cf19\f20\fs22 \u8217?\u8217?\ul0\nosupersub\cf14\f15
\fs22 (p. 1192) \par\pard\qj \li1551\ri694\sb257\sl-264\slmult0\fi478 \up0 \exp
ndtw-9\charscalex100 Developmental disabilities do not usually occur in i
solation. \line \up0 \expndtw-9\charscalex100 In many cases, disabilities may be
present in the same individual but \line \up0 \expndtw-9\charscalex95 in varyin
g degrees. For instance, a person with cerebral palsy (CP) may \line \up0 \expnd
tw-9\charscalex96 have normal or near-normal intelligence or may present
a severe \line \up0 \expndtw-10\charscalex97 degree of mental retardation, may
be verbal or nonverbal, and/or may \line \up0 \expndtw-9\charscalex95 also have
a hearing loss. Similarly, an individual with Down\ul0\nosupersub\cf19\f20\fs22
\u8217?\ul0\nosupersub\cf14\f15\fs22 s syndrome \line \up0 \expndtw-9\charscale
x95 may be nonverbal with hearing loss, mental retardation, and some \l
ine \up0 \expndtw-9\charscalex98 autistic features. Other individuals may have
a hearing loss and also \line \up0 \expndtw-10\charscalex93 present visual impa
irment and some behavioral problems. The presence \line \up0 \expndtw-5\charscal
ex100 of other disabilities in the same individual, no matter how minor or \line
\up0 \expndtw-7\charscalex100 mild, tends to magnify the impact of the
primary disability. For \line \up0 \expndtw-9\charscalex94 instance, take th

e case of an individual who has a mild degree of \line \up0 \expndtw-1

0\charscalex94 mental retardation. The presence of an unidentied and untreated he
ar-\line \up0 \expndtw-9\charscalex97 ing loss in this individual is likel
y to make the mental retardation \line \up0 \expndtw-9\charscalex100 appear
worse than it actually is. Depending on the degree and extent \line \up0 \expnd
tw-9\charscalex95 of occurrence, developmental disabilities pose signicant handic
aps for \line \up0 \expndtw-10\charscalex97 aected individuals, and these often c
an have an impact on their qual-\line \up0 \expndtw-3\charscalex100 ity of life.
The goal of aural rehabilitation of these individuals is to \line \up0 \expndt
w-10\charscalex96 provide audiologic evaluation and ways by which the consequenc
es of
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1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
23}{\bkmkend Pg23}\par\pard\li3525\sb0\sl-241\slmult0\par\pard\li3525\sb0\sl-241
\slmult0\par\pard\li3525\sb201\sl-241\slmult0\fi0\tx7391 \up0 \expndtw-7\charsca
lex100 \ul0\nosupersub\cf17\f18\fs18 Overview of Disabilities\tab \up0 \expndtw9\charscalex100 \ul0\nosupersub\cf14\f15\fs22 3\par\pard\qj \li1286\sb0\sl-250\s
lmult0 \par\pard\qj\li1286\ri961\sb60\sl-250\slmult0 \up0 \expndtw-10\charscalex
96 the handicaps caused by these disabilities can be ameliorated through \up0 \e
xpndtw-9\charscalex95 the use of hearing amplication, augmentative communic
ation, and \up0 \expndtw-10\charscalex90 appropriate referrals. \par\pard\ql \l
i2848\sb0\sl-276\slmult0 \par\pard\ql\li2848\sb233\sl-276\slmult0 \up0 \expndtw0
\charscalex103 \ul0\nosupersub\cf20\f21\fs24 CONCEPT OF DISABILITY \par\pard\qj
\li1286\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb1\sl-258\slmult0\fi478 \u
p0 \expndtw-10\charscalex96 \ul0\nosupersub\cf14\f15\fs22 The terms disability,
handicap, and impairment are often used or \line \up0 \expndtw-9\charscalex95 mi
sused interchangeably in rehabilitation literature. Disability refers to a \line
\up0 \expndtw-9\charscalex94 physical, physiologic, mental, or sensory abnormal
ity, whereas handicap \line \up0 \expndtw-10\charscalex96 refers to the conseque
nces caused by the disability. A handicap is the \line \up0 \expndtw-8\charscale
x100 extent and degree to which a disability impedes, limits, or restricts an \l
ine \up0 \expndtw-9\charscalex96 individual\ul0\nosupersub\cf19\f20\fs22 \u8217?
\ul0\nosupersub\cf14\f15\fs22 s participation in certain activities or tasks for
which a normal \line \up0 \expndtw-9\charscalex96 body function is needed. Disa
bility therefore results in activity limitation \line \up0 \expndtw-9\charscalex
93 or participation restriction as a result of the presence of a phys
ical \line \up0 \expndtw-6\charscalex100 or physiologic dysfunction that an
individual may present. The \line \up0 \expndtw-10\charscalex94 World Health
Organization (1980) denes an impairment as any loss or \line \up0 \expndtw-9\cha
rscalex97 abnormality of psychologic, physiologic, or anatomical structure
or \line \up0 \expndtw-7\charscalex100 function. The degree to which an impair
ment poses a handicap is a \line \up0 \expndtw-9\charscalex100 function of the e
xtent and degree of the impairment itself. Impairment \line \up0 \expndtw-4\char
scalex100 relates to disability in that both occur as a result of loss of functi
on \line \up0 \expndtw-6\charscalex100 of an anatomical or physiologic nature th
at limits activity or restricts \line \up0 \expndtw-9\charscalex97 the individua
l\ul0\nosupersub\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf14\f15\fs22 s participat
ion. Hearing loss, for instance, causes activity \line \up0 \expndtw-5\charscale
x100 limitation \up0 \expndtw-10\charscalex94 (disability) and social/occupati
onal participation restriction \line \up0 \expndtw-10\charscalex88 (handicap).

\par\pard\qj \li1286\ri959\sb1\sl-260\slmult0\fi478 \up0 \expndtw-6\charscalex1

00 Hearing loss is an invisible disability that aects people of any \line \up0 \e
xpndtw-8\charscalex100 age group from neonates to older adults. Hearing impairme
nt of any \line \up0 \expndtw-10\charscalex96 degree or conguration is capable
of compromising communication, \line \up0 \expndtw-9\charscalex98 education, s
ocial functioning, and safety of the individual. The evalua-\line \up0 \expndtw10\charscalex96 tion and management of hearing loss, particularly in infants and
young \line \up0 \expndtw-9\charscalex93 and older adults, can be challengi
ng. However, there is yet another \line \up0 \expndtw-10\charscalex96 group
of people who, apart from having hearing decits, present addi-\line \up0 \expndt
w-9\charscalex93 tional disabilities, disease processes, or dysfunctions t
hat sometimes \line \up0 \expndtw-9\charscalex100 further compromise the heari
ng loss itself. However, such additional \line \up0 \expndtw-10\charscalex96 di
sease processes or conditions may be primary, secondary, or totally \line \up0 \
expndtw-9\charscalex96 unrelated to a hearing loss. These problematic con
ditions may be \line \up0 \expndtw-10\charscalex95 developmental such as menta
l retardation, Down\ul0\nosupersub\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf14\f15
\fs22 s syndrome, cerebral \line \up0 \expndtw-10\charscalex96 palsy, and autism
; may be related to a disease process such as human
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
24}{\bkmkend Pg24}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx3030 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf14\f15\fs22 4\tab \up0 \expndtw-8\charscalex97 \ul0\nos
upersub\cf17\f18\fs18 Aural Rehabilitation of People with Disabilities\par\pard\
ql \li1551\sb0\sl-253\slmult0 \par\pard\ql\li1551\sb82\sl-253\slmult0\tx4734 \up
0 \expndtw-9\charscalex100 \ul0\nosupersub\cf14\f15\fs22 immunodeciency virus i
nfection \tab \up0 \expndtw-10\charscalex96 (HIV)/acquired immunodeciency \par\p
ard\qj \li1551\ri696\sb0\sl-260\slmult0 \up0 \expndtw-9\charscalex100 syndrome
(AIDS) and other conditions that can cause the disruption \line \up0 \expndtw-9\
charscalex98 of auditory or visual function, physical motor function, or
sensory \line \up0 \expndtw-7\charscalex100 motor function; or may be diso
rders in speech, language, and \line \up0 \expndtw-9\charscalex100 cognition
. \par\pard\qj \li1551\ri694\sb0\sl-258\slmult0\fi478 \up0 \expndtw-10\charscale
x94 Despite rapid advancement in medicine, science, and technology, \line \up0 \
expndtw-7\charscalex100 the number of people with disabilities has not yet decre
ased signi-\line \up0 \expndtw-9\charscalex100 cantly. Natural occurrences due to
chromosome defects as well as to \line \up0 \expndtw-9\charscalex97 pre, peri,
and postnatal events and traumatic accidents during delivery \line \up0 \expndtw
-9\charscalex96 have contributed to the numbers of people with disabilit
ies in our \line \up0 \expndtw-9\charscalex95 society. It is also possible tha
t we now have better methods of detecting \line \up0 \expndtw-10\charscalex96 an
d describing new human developmental problems and disease pro-\line \up0 \expndt
w-9\charscalex94 cesses. Some good examples of discoveries of new condit
ions are \line \up0 \expndtw-9\charscalex100 AIDS and severe acute respiratory
syndrome (SARS). It is simply not \line \up0 \expndtw-7\charscalex100 possible t
o be familiar with every known disability. In addition, many \line \up0 \expndtw
-9\charscalex93 times clinicians do not feel they possess adequate train
ing or skills \line \up0 \expndtw-7\charscalex100 to evaluate hearing-impair
ed people with other more commonly \line \up0 \expndtw-10\charscalex97 enco

untered disabilities, such as CP, visual impairment, mental retar-\line \up0 \ex
pndtw-9\charscalex94 dation, dementia, and Down\ul0\nosupersub\cf19\f20\fs22
\u8217?\ul0\nosupersub\cf14\f15\fs22 s syndrome. These disabilities may be
\line \up0 \expndtw-9\charscalex95 primary to, secondary to, or even unrela
ted to hearing impairment. \line \up0 \expndtw-9\charscalex100 Very young and
elderly individuals pose greater challenges for audio-\line \up0 \expndtw-9\cha
rscalex94 logic evaluations and rehabilitation, especially if other disabil
ities are \line \up0 \expndtw-7\charscalex100 present. Usually, a diagnosis of
the dominant disability is important. \line \up0 \expndtw-9\charscalex97 Based
on this diagnosis, specic audiologic test batteries can be \line \up0 \ex
pndtw-10\charscalex83 selected. \par\pard\qj \li1551\ri695\sb0\sl-260\slmult0\fi
478 \up0 \expndtw-10\charscalex94 For instance, the HIV/AIDS epidemic has occurr
ed during the past \line \up0 \expndtw-9\charscalex96 two decades. The literatur
e is replete with reports of structural damage \line \up0 \expndtw-3\charscalex1
00 and loss of function resulting from the impact of HIV/AIDS on the \line \up0
\expndtw-9\charscalex94 auditory system (Grimaldi, et al., 1993; Moazzez & Alvin
, 1998; Pappas, \line \up0 \expndtw-9\charscalex96 Roland, Lim, Lai, & Hillm
an, 1995; Soucek & Michael, 1996). New \line \up0 \expndtw-10\charscalex91 d
isease processes and conditions as exemplied by the recent SARS epi-\line \up0 \e
xpndtw-10\charscalex94 demic will continue to emerge even with advancements in s
ophisticated \line \up0 \expndtw-10\charscalex94 diagnostic and therapeutic meth
ods in science and medicine to address \line \up0 \expndtw-9\charscalex100 known
and unknown pathologic conditions. Some of these pathologic \line \up0 \expndtw
-9\charscalex93 conditions may occur as handicaps that are primary to or associa
ted with \line \up0 \expndtw-9\charscalex96 hearing impairment. Associated or
dominant handicaps in hearing-\line \up0 \expndtw-9\charscalex94 impaired
individuals may sometimes delay the diagnosis of hearing \line \up0 \expn
dtw-10\charscalex94 impairment (Voutilainen, Jauhiainen, & Linkola, 1998). Unti
l recently
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
25}{\bkmkend Pg25}\par\pard\li3525\sb0\sl-241\slmult0\par\pard\li3525\sb0\sl-241
\slmult0\par\pard\li3525\sb201\sl-241\slmult0\fi0\tx7391 \up0 \expndtw-7\charsca
lex100 \ul0\nosupersub\cf17\f18\fs18 Overview of Disabilities\tab \up0 \expndtw9\charscalex100 \ul0\nosupersub\cf14\f15\fs22 5\par\pard\qj \li1286\sb0\sl-262\s
lmult0 \par\pard\qj\li1286\ri959\sb38\sl-262\slmult0 \up0 \expndtw-6\charscalex1
00 hearing impairment was often not thought to be crucial in the initial \line \
up0 \expndtw-8\charscalex100 evaluation of children with disabilities, because i
t was not considered \line \up0 \expndtw-9\charscalex94 a priority in the overal
l rehabilitation process (Friedrich, 1985). However, \line \up0 \expndtw-9\chars
calex93 in the United States, this attitude is changing now that universal neona
tal \line \up0 \expndtw-9\charscalex94 hearing screening programs are in place i
n many states. In these states, \line \up0 \expndtw-9\charscalex93 a hearing scr
eening test is performed on every neonate before discharge \line \up0 \expndtw-9
\charscalex94 from the hospital. In addition, noninvasive and more objective too
ls such \line \up0 \expndtw-10\charscalex96 as otoacoustic emissions and auditor
y brainstem response are now in \line \up0 \expndtw-10\charscalex92 common use.
\par\pard\qj \li1286\ri961\sb0\sl-270\slmult0\fi478 \up0 \expndtw-10\charscalex9
4 However, although these objective electrophysiologic tests gener-\line \up0 \e
xpndtw-8\charscalex100 ally yield a more accurate status of auditory function th

an previously \line \up0 \expndtw-10\charscalex91 used methods, they also ha

ve pitfalls \up0 \expndtw-10\charscalex92 (Worthington & Peters, 1980). \par
\pard\qj \li1286\ri959\sb0\sl-260\slmult0 \up0 \expndtw-9\charscalex93 W|th beh
avioral assessment measures still being widely used, many \line \up0 \exp
ndtw-9\charscalex94 individuals with associated handicaps may still be co
nsidered to be \line \up0 \expndtw-9\charscalex96 untestable, especially when
clinicians are either uncomfortable or unfa-\line \up0 \expndtw-4\charscalex100
miliar with a dominant disability and its eects on hearing function \line \up0 \e
xpndtw-9\charscalex95 and the evaluation process. Some of these disabilities wil
l be discussed \line \up0 \expndtw-10\charscalex95 briey later. \par\pard\ql \li1
692\sb0\sl-276\slmult0 \par\pard\ql\li1692\sb0\sl-276\slmult0 \par\pard\ql\li169
2\sb86\sl-276\slmult0 \up0 \expndtw0\charscalex102 \ul0\nosupersub\cf20\f21\fs24
CONSEQUENCES OF HEARING IMPAIRMENT \par\pard\qj \li1286\ri960\sb256\sl-262\slmu
lt0\fi478 \up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf14\f15\fs22 Because he
aring impairment is an invisible disability, it is easily \line \up0 \expndtw-9\
charscalex95 ignored, especially if other, more dominant, health issues are also
pres-\line \up0 \expndtw-8\charscalex100 ent. If hearing impairment, whether mi
ld or unilateral, is not identied \line \up0 \expndtw-6\charscalex100 early enoug
h either at birth or within the rst 2 years of life it may \line \up0 \expndt
w-10\charscalex93 have serious consequences for the child\ul0\nosupersub\cf19\f2
0\fs22 \u8217?\ul0\nosupersub\cf14\f15\fs22 s speech, language, and cogni-\line
\up0 \expndtw-9\charscalex93 tive skills development. The child\ul0\nosupersub\c
f19\f20\fs22 \u8217?\ul0\nosupersub\cf14\f15\fs22 s educational process and achi
evement \line \up0 \expndtw-10\charscalex97 may also be compromised if a hearing
loss is unidentied and rehabi-\line \up0 \expndtw-9\charscalex97 litation is not
instituted. In the United States, as noted earlier, neonatal \line \up0 \expndt
w-10\charscalex97 hearing screening is now common in many states. Neonates usu
ally \line \up0 \expndtw-8\charscalex100 receive routine screening to rule
out the presence of a hearing \line \up0 \expndtw-7\charscalex100 loss befo
re their discharge from the hospital after delivery. An infant \line \up0 \expnd
tw-9\charscalex94 with suspected hearing loss is followed, and appropriate diagn
ostic and \line \up0 \expndtw-9\charscalex95 rehabilitative measures are put
in place. However, for children with \line \up0 \expndtw-9\charscalex97 mu
ltiple disabilities, the presence of a hearing loss, its evaluation, and \line \
up0 \expndtw-10\charscalex94 rehabilitation constitute additional challenges.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
26}{\bkmkend Pg26}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx3030 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf14\f15\fs22 6\tab \up0 \expndtw-8\charscalex97 \ul0\nos
upersub\cf17\f18\fs18 Aural Rehabilitation of People with Disabilities\par\pard\
ql \li3175\sb0\sl-276\slmult0 \par\pard\ql\li3175\sb60\sl-276\slmult0 \up0 \expn
dtw0\charscalex105 \ul0\nosupersub\cf20\f21\fs24 MENTAL RETARDATION \par\pard\qj
\li1551\ri694\sb239\sl-259\slmult0\fi478 \up0 \expndtw-7\charscalex100 \ul0\nos
upersub\cf14\f15\fs22 Audiologic evaluation, particularly the behavioral as
pect, is \line \up0 \expndtw-9\charscalex98 an interactive process. The
clinician and the individual being \line \up0 \expndtw-7\charscalex100 t
ested must interact communicatively with each other to obtain \line \up0
\expndtw-9\charscalex97 accurate hearing thresholds. This interaction requires
a minimal level \line \up0 \expndtw-7\charscalex100 of intellectual function

ing and adaptive abilities for an individual \line \up0 \expndtw-10\charsc

alex95 to respond appropriately to speech and acoustic stimuli. Chromosomal \lin
e \up0 \expndtw-7\charscalex100 abnormalities, heredity, pre- and perinatal
infections, intrauterine \line \up0 \expndtw-9\charscalex96 growth retardatio
n, and inappropriate or indiscriminate exposure of \line \up0 \expndtw-9\c
harscalex94 the fetus to drugs during pregnancy are common causes of me
ntal \line \up0 \expndtw-9\charscalex95 retardation. Socioeconomic factors su
ch as poor nutrition, maternal \line \up0 \expndtw-7\charscalex100 neglect,
and poverty can compound preexisting low intellectual \line \up0 \expndtw
-6\charscalex100 function. Although there is some disagreement concerning
the \line \up0 \expndtw-7\charscalex100 use of the term mental retardation, the
re is unanimity that an individ-\line \up0 \expndtw-5\charscalex100 ual with t
his condition must exhibit low intellectual functioning, \line \up0 \expnd
tw-9\charscalex98 an impairment due to physical insult, disease, or an
abnormality \line \up0 \expndtw-9\charscalex93 before age 18, and an impairm
ent in adaptive abilities (Batshaw and \line \up0 \expndtw-10\charscalex89 S
hapiro, \up0 \expndtw-10\charscalex93 1997). IQ scores, age of onset, and
adaptive impairments \line \up0 \expndtw-9\charscalex94 (although still cont
roversial) have often been used to dene mental \line \up0 \expndtw-9\chars
calex96 retardation. According to the American Psychiatric Association (1994),
\line \up0 \expndtw-4\charscalex100 a person with mental retardation should
exhibit the following \line \up0 \expndtw-7\charscalex100 characteristics:
an IQ score of \up0 \expndtw-10\charscalex84 70 \up0 \expndtw-4\charscalex100
or less on an individually \par\pard\qj \li1551\ri695\sb1\sl-260\slmult0 \u
p0 \expndtw-7\charscalex100 administered IQ test, concurrent decits in adap
tive functioning, \line \up0 \expndtw-8\charscalex100 and onset before the age
of 18 years. Impairment in adaptive ability \line \up0 \expndtw-9\charscalex97
is demonstrated by the person\ul0\nosupersub\cf19\f20\fs22 \u8217?\ul0\nosupersu
b\cf14\f15\fs22 s inability to perform at least two cultur-\line \up0 \expndtw-9
\charscalex95 ally expected and age-appropriate skills required for everyd
ay living \line \up0 \expndtw-9\charscalex96 such as communication, self-care, s
ocial/interpersonal skills, functional \line \up0 \expndtw-9\charscalex93 academ
ic skills, home living, safe use of community resources, and \line \up0
\expndtw-8\charscalex100 self-direction in work, leisure activities, and
health. Some of the \line \up0 \expndtw-6\charscalex100 everyday living skill
s that are vital during audiologic evaluation and \line \up0 \expndtw-10\charsca
lex97 rehabilitation are easily compromised by more severe mental retarda-\line
\up0 \expndtw-9\charscalex96 tion. For instance, a person with mild mental
retardation (IQ score \line \up0 \expndtw-10\charscalex96 of approximately 7
0) would perform much better on speech measures \line \up0 \expndtw-9\charscalex
97 that require repeating words or sentences than an individual with \l
ine \up0 \expndtw-10\charscalex94 severe retardation (IQ score of approximately
35).
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
27}{\bkmkend Pg27}\par\pard\li3525\sb0\sl-241\slmult0\par\pard\li3525\sb0\sl-241
\slmult0\par\pard\li3525\sb201\sl-241\slmult0\fi0\tx7391 \up0 \expndtw-7\charsca
lex100 \ul0\nosupersub\cf17\f18\fs18 Overview of Disabilities\tab \up0 \expndtw9\charscalex100 \ul0\nosupersub\cf14\f15\fs22 7\par\pard\ql \li3128\sb0\sl-276\s
lmult0 \par\pard\ql\li3128\sb33\sl-276\slmult0 \up0 \expndtw0\charscalex102 \ul0

\nosupersub\cf20\f21\fs24 DOWN\ul0\nosupersub\cf21\f22\fs24 \u8217?\ul0\nosupers

ub\cf20\f21\fs24 S SYNDROME \par\pard\qj \li1286\ri959\sb234\sl-264\slmult0\fi47
8 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf14\f15\fs22 Down\ul0\nosupersu
b\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf14\f15\fs22 s syndrome is caused by
three types of chromosomal \line \up0 \expndtw-9\charscalex93 abnormalities
: trisomy 21, translocation, and mosaicism. People with \line \up0 \expnd
tw-9\charscalex94 Down\ul0\nosupersub\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf14\
f15\fs22 s syndrome often have craniofacial anomalies and are prone \lin
e \up0 \expndtw-9\charscalex98 to having pathologic conditions of the
middle ear, especially \line \up0 \expndtw-10\charscalex97 Eustachian tub
e dysfunction. Hearing impairment occurs in about \line \up0 \expndtw-6\ch
arscalex100 60 ^ 80% of individuals with Down\ul0\nosupersub\cf19\f20\fs22 \u821
7?\ul0\nosupersub\cf14\f15\fs22 s syndrome (MCW Health Link; \line \up0 \expndt
w-9\charscalex95 2002; Roizen, Wolters, Nicol, & Blondis, 1993), who exhib
it various \line \up0 \expndtw-8\charscalex100 degrees and types of hearing imp
airment. Although the hearing loss \line \up0 \expndtw-9\charscalex96 can be s
ensorineural, conductive, or mixed conductive, conductive \line \up0 \expnd
tw-5\charscalex100 hearing loss is the most commonly occurring type of
hearing \line \up0 \expndtw-9\charscalex94 loss seen in this group. Smaller
and narrow ear canals, which are \line \up0 \expndtw-9\charscalex97 often
impacted with cerumen are common, especially in children. \line \up0 \e
xpndtw-8\charscalex100 Audiologic management of this group involves a series of
audiologic \line \up0 \expndtw-9\charscalex98 evaluations, medical or surgical i
ntervention, use of amplication, and \line \up0 \expndtw-10\charscalex90 caregive
r education. \par\pard\ql \li3289\sb0\sl-276\slmult0 \par\pard\ql\li3289\sb0\sl276\slmult0 \par\pard\ql\li3289\sb0\sl-276\slmult0 \par\pard\ql\li3289\sb59\sl-2
76\slmult0 \up0 \expndtw0\charscalex101 \ul0\nosupersub\cf20\f21\fs24 CEREBRAL P
ALSY \par\pard\qj \li1286\ri961\sb254\sl-264\slmult0\fi478 \up0 \expndtw-10\char
scalex92 \ul0\nosupersub\cf14\f15\fs22 CP is a condition, not a disease. Cerebra
l palsy is an umbrella term \line \up0 \expndtw-9\charscalex98 used to describ
e disorders of motor function resulting from brain \line \up0 \expndtw-9\
charscalex97 injury or malfunction. Brain injuries that cause CP often m
ay also \line \up0 \expndtw-9\charscalex93 result in other associated problems
such as hearing and vision disorders, \line \up0 \expndtw-9\charscalex100 mental
retardation, and speech and language impairment. CP is \line \up0 \expn
dtw-10\charscalex94 associated with two main types of brain injury: spas
tic \up0 \expndtw-10\charscalex95 (pyramidal) \par\pard\qj \li1286\ri959\sb0\sl263\slmult0 \up0 \expndtw-7\charscalex100 and athetoid (extrapyramidal). The mo
st common form of CP is the \line \up0 \expndtw-9\charscalex96 spastic type, whi
ch is characterized by tense, contracted muscles and \line \up0 \expndtw-8\cha
rscalex100 limited movements of the head, neck, and limbs. Both forms
of \line \up0 \expndtw-9\charscalex96 CP have implications for audiologic a
ssessment and rehabilitation, \line \up0 \expndtw-8\charscalex100 especially i
n terms of selection of test battery, evaluation techniques, \line \up0 \expndtw
-9\charscalex92 testee response modes, hearing instruments, and rehabilita
tion when \line \up0 \expndtw-10\charscalex92 indicated.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
28}{\bkmkend Pg28}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
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alex97 \ul0\nosupersub\cf14\f15\fs22 8\tab \up0 \expndtw-8\charscalex97 \ul0\nos

upersub\cf17\f18\fs18 Aural Rehabilitation of People with Disabilities\par\pard\
ql \li4113\sb0\sl-276\slmult0 \par\pard\ql\li4113\sb60\sl-276\slmult0 \up0 \expn
dtw0\charscalex104 \ul0\nosupersub\cf20\f21\fs24 HIV/AIDS \par\pard\qj \li1551\r
i694\sb236\sl-262\slmult0\fi478 \up0 \expndtw-10\charscalex89 \ul0\nosupersub\cf
14\f15\fs22 AIDS is caused by HIV. The disease, rst described in 1981, has had \l
ine \up0 \expndtw-9\charscalex95 devastating eects on health, including the heari
ng health of those living \line \up0 \expndtw-9\charscalex96 with AIDS. AIDS
gradually and gravely aects the central nervous \line \up0 \expndtw-9\chars
calex93 system (CNS) with substantial manifestations in the head and ne
ck \line \up0 \expndtw-7\charscalex100 regions of the body in which the auditory
system is also extensively \line \up0 \expndtw-10\charscalex86 represented \up0
\expndtw-10\charscalex94 (Bankaitis & Keith, 1995; Lalwani & Sooy, 1992;
Real, \line \up0 \expndtw-10\charscalex96 Thomas, & Gerwins, 1987; T|mon &
Walsh, 1989). Thus many HIV-\line \up0 \expndtw-9\charscalex97 infected individ
uals often report a triad of vertigo, tinnitus, and hearing \line \up0 \expndtw9\charscalex95 loss. However, HIV does not directly produce hearing loss;
hearing \line \up0 \expndtw-9\charscalex95 impairment results from opportunist
ic infections caused by the manifes-\line \up0 \expndtw-9\charscalex94 tation of
HIV infection (Rarey, 1990;W|lson, 1986). Otitis media, which is \line \up0 \ex
pndtw-8\charscalex100 prevalent in this population, is often caused by opportuni
stic infecting \line \up0 \expndtw-9\charscalex93 agents secondary to HIV infect
ion (Lalwani & Sooy, 1992). Sensorineural \line \up0 \expndtw-10\charscalex97 he
aring loss also occurs commonly in this population, in part because \line \up0 \
expndtw-9\charscalex100 of heavy reliance on cocktails of experimental and poten
tially ototoxic \line \up0 \expndtw-10\charscalex96 antibiotics for the medical
management of patients living with HIV. \par\pard\ql \li3355\sb0\sl-276\slmult0
\par\pard\ql\li3355\sb0\sl-276\slmult0 \par\pard\ql\li3355\sb95\sl-276\slmult0 \
up0 \expndtw0\charscalex105 \ul0\nosupersub\cf20\f21\fs24 VISUAL IMPAIRMENT \par
\pard\qj \li1551\ri697\sb253\sl-266\slmult0\fi478 \up0 \expndtw-10\charscalex93
\ul0\nosupersub\cf14\f15\fs22 There are various degrees of visual impairment tha
t are dened by \line \up0 \expndtw-5\charscalex100 the extent of visual acuity. A
n individual who has a visual acuity of \line \up0 \expndtw-9\charscalex97 20/20
0 or worse in the better eye with correction or a visual eld \line \up0
\expndtw-10\charscalex90 that is greater than a \up0 \expndtw-10\charscalex
90 20 -degree angle is regarded to be legally blind \par\pard\qj \li1551\ri6
97\sb0\sl-260\slmult0\tx2390 \up0 \expndtw-10\charscalex92 (Bishop, \tab \up0 \e
xpndtw-8\charscalex100 1991). According to the Education for All Handicap
ped \line\up0 \expndtw-9\charscalex95 Children Act of 1995 (PL 94 -142) and Bu
ncic (1987), partially sighted \line \up0 \expndtw-7\charscalex100 individuals
or individuals with low vision, on the other hand, have \line \up0 \expndtw
-8\charscalex100 a visual acuity that is better than \up0 \expndtw-10\char
scalex87 20/200 \up0 \expndtw-8\charscalex100 but worse than \up0 \expndtw-10\
charscalex86 20/70 \par\pard\qj \li1551\ri695\sb0\sl-263\slmult0 \up0 \expndtw-9
\charscalex96 with correction. Although some people who are considered l
egally \line \up0 \expndtw-7\charscalex100 blind may have su\u8260?cient residua
l vision to be able to identify various \line \up0 \expndtw-9\charscalex95 objec
ts and colors and read large print, others lack light and dark \line
\up0 \expndtw-10\charscalex91 perception (Menacker & Batshaw, 1997). V|sual impa
irment has consider-\line \up0 \expndtw-7\charscalex100 able implications for th
e way hearing is evaluated in terms of choice \line \up0 \expndtw-7\charscalex10
0 of test materials and method of evaluation and the test environment \line \up0
\expndtw-10\charscalex91 itself.
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}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
29}{\bkmkend Pg29}\par\pard\li3525\sb0\sl-241\slmult0\par\pard\li3525\sb0\sl-241
\slmult0\par\pard\li3525\sb201\sl-241\slmult0\fi0\tx7391 \up0 \expndtw-7\charsca
lex100 \ul0\nosupersub\cf17\f18\fs18 Overview of Disabilities\tab \up0 \expndtw9\charscalex100 \ul0\nosupersub\cf14\f15\fs22 9\par\pard\qj \li1286\sb0\sl-256\s
lmult0 \par\pard\qj\li1286\ri959\sb49\sl-256\slmult0\fi478 \up0 \expndtw-10\char
scalex95 Although visual impairment can be a standalone disability, often it \li
ne \up0 \expndtw-9\charscalex94 occurs in association with other disabilities su
ch as diabetes. Congenital \line \up0 \expndtw-9\charscalex100 causes of visua
l impairment commonly are intrauterine infections \line \up0 \expndtw-9\cha
rscalex94 and malformation of the visual system itself. Infections and other cau
ses \line \up0 \expndtw-10\charscalex94 of blindness such as brain trauma and an
oxia are commonly associated \line \up0 \expndtw-9\charscalex95 with other dis
abilities such as hearing impairment, CP, and mental \line \up0 \expndtw10\charscalex91 retardation. \par\pard\qj \li1286\ri961\sb1\sl-260\slmult0\fi478
\up0 \expndtw-9\charscalex93 Apart from the disorders briey discussed here,
hearing loss is \up0 \expndtw-9\charscalex95 found as a signicant componen
t in nearly 400 dierent syndromes \up0 \expndtw-9\charscalex93 (Schaefer, 19
95). Schaefer reported the top 10 syndromes that are most \up0 \expndtw-10\char
scalex93 commonly associated with hearing impairment as follows: \par\pard\ql \l
i1845\sb126\sl-253\slmult0 \up0 \expndtw-10\charscalex93 1. Hemifacial microsom
ia \par\pard\ql \li1854\sb7\sl-253\slmult0 \up0 \expndtw-10\charscalex93 2. Sti
ckler syndrome \par\pard\ql \li1845\sb7\sl-253\slmult0 \up0 \expndtw-10\charscal
ex95 3. Congenital cytomegalovirus virus infection \par\pard\ql \li1838\sb1\sl237\slmult0 \up0 \expndtw-10\charscalex89 4. Usher\ul0\nosupersub\cf19\f20\fs22
\u8217?\ul0\nosupersub\cf14\f15\fs22 s syndrome \par\pard\ql \li1847\sb10\sl-25
3\slmult0 \up0 \expndtw-10\charscalex93 5. Branchio-otorenal syndrome \par\pard
\ql \li1843\sb7\sl-253\slmult0 \up0 \expndtw-10\charscalex87 6. Pendred\ul0\nos
upersub\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf14\f15\fs22 s syndrome \par\pard\
ql \li1840\sb7\sl-253\slmult0 \up0 \expndtw-10\charscalex93 7. CHARGE associati
on \par\pard\ql \li1845\sb7\sl-253\slmult0 \up0 \expndtw-10\charscalex94 8. Neu
robromatosis type II \par\pard\ql \li1840\sb7\sl-253\slmult0 \up0 \expndtw-10\cha
rscalex94 9. Mitochondrial disorders \par\pard\ql \li1764\sb7\sl-253\slmult0 \u
p0 \expndtw-10\charscalex91 10. Waardenburg syndrome \par\pard\qj \li1286\ri961\
sb142\sl-260\slmult0 \up0 \expndtw-9\charscalex94 The incidence, identifying
features, types of auditory disorders, and \up0 \expndtw-10\charscalex95 he
aring loss that are associated with these syndromes are displayed in \up0 \expnd
tw-10\charscalex81 Table 1.1. \par\pard\ql \li2871\sb0\sl-276\slmult0 \par\pard\
ql\li2871\sb231\sl-276\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf2
0\f21\fs24 SOCIOCULTURAL ISSUES \par\pard\qj \li1286\ri959\sb258\sl-260\slmult0\
fi478 \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf14\f15\fs22 The Americans
with Disabilities Act of 1990 mandates accessibil-\line \up0 \expndtw-6\charscal
ex100 ity for the hearing impaired as well as for people with other disabil-\lin
e \up0 \expndtw-9\charscalex94 ities. Parental beliefs, attitudes, and cult
ural practices have a great \line \up0 \expndtw-9\charscalex96 inuence on acc
eptance of their children\ul0\nosupersub\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf
14\f15\fs22 s disabilities and their motiva-\line \up0 \expndtw-10\charscalex96
tion to get actively involved in rehabilitation (Danseco, \up0 \expndtw-10\chars
calex90 1997; Mardiros, \par\pard\qj \li1286\ri961\sb0\sl-260\slmult0 \up0 \expn
dtw-9\charscalex92 1989). For instance, a parent who believes that a chi
ld\ul0\nosupersub\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf14\f15\fs22 s disabili
ty is \line \up0 \expndtw-5\charscalex100 temporary only and hopes that the chi
ld will outgrow the problems \line \up0 \expndtw-8\charscalex100 (Danseco, 1997)
will not be easily persuaded to seek help for his or \line \up0 \expndtw-9\cha
rscalex97 her child. Some parents believe that the arrival of a handicapped chil
d

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}}\par\pard\sect\sectd\fs24\landscape\paperw13020\paperh8700\pard\sb0\sl-240{\bk
mkstart Pg30}{\bkmkend Pg30}\par\pard\ql \li6556\sb0\sl-207\slmult0 \par\pard\ql
\li6556\sb0\sl-207\slmult0 \par\pard\ql\li6556\sb0\sl-207\slmult0 \par\pard\ql\l
i6556\sb0\sl-207\slmult0 \par\pard\ql\li6556\sb0\sl-207\slmult0 \par\pard\ql\li6
556\sb0\sl-207\slmult0 \par\pard\ql\li6556\sb67\sl-207\slmult0 \up0 \expndtw-8\c
harscalex92 \ul0\nosupersub\cf17\f18\fs18 Table 1.1 \par\pard\ql \li4809\sb73\sl
-207\slmult0 \up0 \expndtw-3\charscalex100 Syndromes Associated with Significant
Hearing Loss \par\pard\li1964\sb139\sl-184\slmult0\fi3965\tx8217 \up0 \expndtw7\charscalex95 \ul0\nosupersub\cf22\f23\fs16 Common identifying\tab \up0 \expndt
w-7\charscalex95 Auditory disor\par\pard\li1964\sb15\sl-184\slmult0\fi0\tx4408\t
x6374\tx8459 \up0 \expndtw-7\charscalex95 Syndrome\tab \up0 \expndtw-7\charscale
x95 Incidence\tab \up0 \expndtw-7\charscalex95 features\tab \up0 \expndtw-7\char
scalex95 hearin\par\pard\li1964\sb87\sl-184\slmult0\fi0\tx4375\tx5463\tx7799 \up
0 \expndtw-7\charscalex95 1. Hemifacial microsomia\tab \up0 \expndtw-7\charscale
x95 Unknown\tab \up0 \expndtw-7\charscalex95 Facial asymmetry\tab \up0 \expndtw7\charscalex95 Conductive and/o\par\pard\li1964\sb16\sl-184\slmult0\fi318\tx5463
\tx7957 \up0 \expndtw-7\charscalex95 (oculoauriculovertebral\tab \up0 \expndtw-7
\charscalex95 Ocular abnormalities\tab \up0 \expndtw-7\charscalex95 sensorineura
l\par\pard\li1964\sb15\sl-184\slmult0\fi318\tx5622\tx7799 \up0 \expndtw-7\charsc
alex95 dysplasia, Goldenhar\ul0\nosupersub\cf23\f24\fs16 \u8217?\ul0\nosupersub\
cf22\f23\fs16 s\tab \up0 \expndtw-7\charscalex95 (anophthalmia, micro-\tab \up0
\expndtw-7\charscalex95 Auricular abnorm\par\pard\li1964\sb16\sl-184\slmult0\fi3
18\tx5622\tx7799 \up0 \expndtw-7\charscalex95 syndrome)\tab \up0 \expndtw-7\char
scalex95 ophthalmia, and\tab \up0 \expndtw-7\charscalex95 Anomalies of mi\par\pa
rd\li5463\sb14\sl-184\slmult0\fi158\tx7957 \up0 \expndtw-7\charscalex93 epibulba
r dermoids)\tab \up0 \expndtw-7\charscalex93 and external ears\par\pard\li5463\s
b16\sl-184\slmult0\fi0\tx7799 \up0 \expndtw-7\charscalex93 Auricular abnormaliti
es\tab \up0 \expndtw-7\charscalex93 Eustachian tube\par\pard\li5463\sb15\sl-184\
slmult0\fi158\tx7957 \up0 \expndtw-7\charscalex93 (microtia, atresia, anotia)\ta
b \up0 \expndtw-7\charscalex93 malformations\par\pard\li5463\sb15\sl-184\slmult0
\fi0\tx7957 \up0 \expndtw-7\charscalex93 Cervical spine and cranial\tab \up0 \ex
pndtw-7\charscalex93 dysfunction\par\pard\li5463\sb15\sl-184\slmult0\fi158\tx779
9 \up0 \expndtw-7\charscalex93 base malformations\tab \up0 \expndtw-7\charscalex
93 Cranial nerve and\par\pard\li1964\sb16\sl-184\slmult0\fi5993 \up0 \expndtw-7\
charscalex93 skull cranial base\par\pard\li1964\sb16\sl-184\slmult0\fi5993 \up0
\expndtw-7\charscalex93 abnormalities\par\pard\li1964\sb14\sl-184\slmult0\fi0\tx
4374\tx5463\tx7799 \up0 \expndtw-7\charscalex93 2. Stickler syndrome\tab \up0 \e
xpndtw-7\charscalex93 Unknown\tab \up0 \expndtw-7\charscalex93 Craniofacial abno
rmalities\tab \up0 \expndtw-7\charscalex93 Conductive hear\par\pard\li1964\sb16\
sl-184\slmult0\fi318\tx5463\tx7799 \up0 \expndtw-7\charscalex93 (Marshall-Stickl
er\tab \up0 \expndtw-7\charscalex93 Cleft palate\tab \up0 \expndtw-7\charscalex9
3 Progressive senso\par\pard\li1964\sb15\sl-184\slmult0\fi318\tx5463\tx7799 \up0
\expndtw-7\charscalex93 syndrome, hereditary\tab \up0 \expndtw-7\charscalex93 F
lattening of the face\tab \up0 \expndtw-7\charscalex93 Eustachian tube\par\pard\
li1964\sb16\sl-184\slmult0\fi318\tx5463\tx7957 \up0 \expndtw-7\charscalex93 arth
ro-ophthalmopathy)\tab \up0 \expndtw-7\charscalex93 Ocular changes\tab \up0 \exp
ndtw-7\charscalex93 dysfunction (ca\par\pard\li1964\sb14\sl-184\slmult0\fi3499\t
x7957 \up0 \expndtw-7\charscalex94 Arthropathy\tab \up0 \expndtw-7\charscalex94
cleft palate)\par\pard\li1964\sb16\sl-184\slmult0\fi0\tx4428\tx5463\tx7799 \up0

\expndtw-7\charscalex94 3. Congenital\tab \up0 \expndtw-7\charscalex94 1 of 3500

\tab \up0 \expndtw-7\charscalex94 Jaundice, hemolytic amnesia,\tab \up0 \expndtw
-7\charscalex94 Sensorineural (m\par\pard\li1964\sb15\sl-184\slmult0\fi318\tx455
4\tx5622\tx7957 \up0 \expndtw-7\charscalex94 cytomegalovirus\tab \up0 \expndtw-7
\charscalex94 live births\tab \up0 \expndtw-7\charscalex94 thrombocytopenia,\tab
\up0 \expndtw-7\charscalex94 progressive)\par\pard\li1964\sb15\sl-184\slmult0\f
i318\tx5622 \up0 \expndtw-7\charscalex94 infection (CMV)\tab \up0 \expndtw-7\cha
rscalex94 hepatosplenomegaly\par\pard\ql \li5463\sb12\sl-184\slmult0 \up0 \expnd
tw-7\charscalex97 Microcephaly \par\pard\ql \li5463\ri5907\sb3\sl-200\slmult0 \u
p0 \expndtw-7\charscalex92 Cerebral calcifications \line \up0 \expndtw-7\charsca
lex91 Central nervous system \line \up0 \expndtw-7\charscalex92 disruptions
{\shp {\*\shpinst\shpleft1964\shptop2108\shpright11808\shpbottom2128\shpfhdr0\sh
pbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz6\shplid0
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{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1964\shptop2586\shpright7799\shpbottom2606\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 5835}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(5835,20);(5835,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft7799\shptop2586\shpright9895\shpbottom2606\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz10\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 2096}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(2096,20);(2096,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\landscape\paperw13020\paperh8700\pard\sb0\sl-240{\bk
mkstart Pg31}{\bkmkend Pg31}\par\pard\li1963\sb0\sl-184\slmult0\par\pard\li1963\
sb0\sl-184\slmult0\par\pard\li1963\sb0\sl-184\slmult0\par\pard\li1963\sb0\sl-184
\slmult0\par\pard\li1963\sb152\sl-184\slmult0\fi0\tx4255\tx5462\tx7796 \up0 \exp
ndtw-7\charscalex90 \ul0\nosupersub\cf22\f23\fs16 4. Usher\ul0\nosupersub\cf23\f
24\fs16 \u8217?\ul0\nosupersub\cf22\f23\fs16 s syndrome\tab \up0 \expndtw-7\char
scalex90 3.5 per 100,000\tab \up0 \expndtw-7\charscalex90 Retinitis pigmentosa\t
ab \up0 \expndtw-7\charscalex90 Moderate to sever\par\pard\li4393\sb16\sl-184\sl
mult0\fi0\tx5462\tx7955 \up0 \expndtw-7\charscalex91 live births\tab \up0 \expnd
tw-7\charscalex91 Sensorineural loss\tab \up0 \expndtw-7\charscalex91 sensorineu
ral\par\pard\li5462\sb14\sl-184\slmult0\fi0\tx7796 \up0 \expndtw-7\charscalex94
Absent vestibular\tab \up0 \expndtw-7\charscalex94 Severe to profoun\par\pard\li
5462\sb16\sl-184\slmult0\fi158\tx7955 \up0 \expndtw-7\charscalex94 function in t
ype I\tab \up0 \expndtw-7\charscalex94 sensorineural\par\pard\ql \li7796\sb0\sl-

182\slmult0 \up0 \expndtw-7\charscalex89 Progressive (in so \par\pard\ql \li7955

\ri3704\sb4\sl-200\slmult0 \up0 \expndtw-7\charscalex96 10% of individuals \line
\up0 \expndtw-7\charscalex100 retinitis pigme \line \up0 \expndtw-7\charscalex9
0 hearing loss \line \up0 \expndtw-7\charscalex95 10% of childre \line \up0 \exp
ndtw-7\charscalex90 sensorineural heari \line \up0 \expndtw-7\charscalex88 have
Usher\ul0\nosupersub\cf23\f24\fs16 \u8217?\ul0\nosupersub\cf22\f23\fs16 s syndr
\par\pard\li1963\sb26\sl-184\slmult0\fi0\tx3987\tx5462\tx7796 \up0 \expndtw-7\ch
arscalex94 5. Branchio-otorenal\tab \up0 \expndtw-7\charscalex89 1 per 40,000 li
ve births\tab \up0 \expndtw-7\charscalex94 Branchial clefts\tab \up0 \expndtw-7\
charscalex94 Significant hearin\par\pard\li1963\sb15\sl-184\slmult0\fi317\tx4145
\tx5462\tx7955 \up0 \expndtw-7\charscalex94 syndrome (BOR)\tab \up0 \expndtw-7\c
harscalex94 2% of children with\tab \up0 \expndtw-7\charscalex94 Fistulas and cy
sts\tab \up0 \expndtw-7\charscalex94 30% conductiv\par\pard\li1963\sb16\sl-184\s
lmult0\fi2182\tx5462\tx7955 \up0 \expndtw-7\charscalex94 profound hearing\tab \u
p0 \expndtw-7\charscalex94 Malformation of pinnae\tab \up0 \expndtw-7\charscalex
94 20% sensorine\par\pard\li1963\sb14\sl-184\slmult0\fi2182\tx5462\tx7955 \up0 \
expndtw-7\charscalex94 loss may have\tab \up0 \expndtw-7\charscalex94 Preauricul
ar pits\tab \up0 \expndtw-7\charscalex94 50% Mixed\par\pard\li1963\sb16\sl-184\s
lmult0\fi2182 \up0 \expndtw-7\charscalex94 BOR\par\pard\li1963\sb16\sl-184\slmul
t0\fi0\tx3987\tx5462\tx7796 \up0 \expndtw-7\charscalex94 6. Pendred\ul0\nosupers
ub\cf23\f24\fs16 \u8217?\ul0\nosupersub\cf22\f23\fs16 s syndrome\tab \up0 \expnd
tw-7\charscalex94 5% of individuals\tab \up0 \expndtw-7\charscalex94 Thyroid goi
ter\tab \up0 \expndtw-7\charscalex94 Hearing loss ofte\par\pard\li4145\sb14\sl-1
84\slmult0\fi0\tx5462\tx7796 \up0 \expndtw-7\charscalex93 with congenital\tab \u
p0 \expndtw-7\charscalex93 Profound congenital\tab \up0 \expndtw-7\charscalex93
Severe hearing loss\par\pard\li4145\sb15\sl-184\slmult0\fi0\tx5621\tx7955 \up0 \
expndtw-7\charscalex93 hearing loss\tab \up0 \expndtw-7\charscalex93 sensorineur
al\tab \up0 \expndtw-7\charscalex93 more than 50%\par\pard\li1963\sb16\sl-184\sl
mult0\fi3657\tx7796 \up0 \expndtw-7\charscalex94 hearing loss\tab \up0 \expndtw7\charscalex94 Progressive heari\par\pard\li1963\sb16\sl-184\slmult0\fi0\tx3987\
tx5462\tx7796 \up0 \expndtw-7\charscalex94 7. CHARGE association\tab \up0 \expnd
tw-7\charscalex94 Unknown\tab \up0 \expndtw-7\charscalex94 Coloboma\tab \up0 \ex
pndtw-7\charscalex94 Mixed hearing loss\par\pard\li5462\sb14\sl-184\slmult0\fi0\
tx7955 \up0 \expndtw-7\charscalex96 Heart problems\tab \up0 \expndtw-7\charscale
x96 80^85% of indi\par\pard\li5462\sb16\sl-184\slmult0\fi0\tx7955 \up0 \expndtw7\charscalex96 Atresia\tab \up0 \expndtw-7\charscalex96 with CHARGE\par\pard\li5
462\sb15\sl-184\slmult0\fi0\tx7955 \up0 \expndtw-7\charscalex96 Retarded growth\
tab \up0 \expndtw-7\charscalex96 hearing loss\par\pard\qj \li5462\ri5997\sb0\sl200\slmult0\fi158 \up0 \expndtw-7\charscalex93 and development \line \up0 \expnd
tw-7\charscalex93 Genital hyperplasia \line \up0 \expndtw-7\charscalex88 Ear ano
maly/ deafness \par\pard\ql \li5621\sb14\sl-184\slmult0 \up0 \expndtw-2\charscal
ex100 (CHARGE)
{\shp {\*\shpinst\shpleft1963\shptop6798\shpright11806\shpbottom6818\shpfhdr0\sh
pbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz6\shplid0
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(9843,20);(9843,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\landscape\paperw13020\paperh8700\pard\sb0\sl-240{\bk
mkstart Pg32}{\bkmkend Pg32}\par\pard\qj \li6447\sb0\sl-280\slmult0 \par\pard\qj
\li6447\sb0\sl-280\slmult0 \par\pard\qj\li6447\sb0\sl-280\slmult0 \par\pard\qj\l
i6447\sb0\sl-280\slmult0 \par\pard\qj\li6447\sb0\sl-280\slmult0 \par\pard\qj\li6
447\ri5516\sb209\sl-280\slmult0\fi96 \up0 \expndtw-8\charscalex92 \ul0\nosupersu
b\cf17\f18\fs18 Table 1.1 \line \up0 \expndtw-8\charscalex93 \ul0\nosupersub\cf2
4\f25\fs18 (\ul0\nosupersub\cf17\f18\fs18 Continued\ul0\nosupersub\cf24\f25\fs18

) \par\pard\li1953\sb126\sl-184\slmult0\fi4188\tx8294 \up0 \expndtw-7\charscale

x94 \ul0\nosupersub\cf22\f23\fs16 Common identifying\tab \up0 \expndtw-7\charsca
lex94 Auditory\par\pard\li1953\sb14\sl-184\slmult0\fi0\tx4481\tx6586\tx8536 \up0
\expndtw-7\charscalex94 Syndrome\tab \up0 \expndtw-7\charscalex94 Incidence\tab
\up0 \expndtw-7\charscalex94 features\tab \up0 \expndtw-7\charscalex94 heari\pa
r\pard\li1953\sb89\sl-184\slmult0\fi0\tx4147\tx5951\tx8238 \up0 \expndtw-7\chars
calex94 8. Neurofibromatosis\tab \up0 \expndtw-7\charscalex94 1 in 40,000\tab \u
p0 \expndtw-7\charscalex94 Vestibular schwannomas\tab \up0 \expndtw-7\charscalex
94 Unilateral\par\pard\li1953\sb14\sl-184\slmult0\fi317\tx4305\tx5951\tx8238 \up
0 \expndtw-7\charscalex94 type II\tab \up0 \expndtw-7\charscalex94 (children) 1
in\tab \up0 \expndtw-7\charscalex94 Intracranial tumors\tab \up0 \expndtw-7\char
scalex94 Progressiv\par\pard\ql \li4424\sb1\sl-184\slmult0\tx4941 \up0 \expndtw7\charscalex87 200,000 \tab \up0 \expndtw-7\charscalex92 (adults) \par\pard\li19
53\sb0\sl-184\slmult0\par\pard\li1953\sb0\sl-184\slmult0\par\pard\li1953\sb0\sl184\slmult0\par\pard\li1953\sb0\sl-184\slmult0\par\pard\li1953\sb91\sl-184\slmul
t0\fi0\tx4147\tx5951\tx8238 \up0 \expndtw-7\charscalex95 9. Mitochondrial disord
ers\tab \up0 \expndtw-7\charscalex95 Unknown\tab \up0 \expndtw-7\charscalex95 He
aring loss\tab \up0 \expndtw-7\charscalex95 Sensorineur\par\pard\qj \li5951\ri57
99\sb0\sl-200\slmult0 \up0 \expndtw-7\charscalex91 Seizure disorder \line \up0 \
expndtw-7\charscalex93 Diabetes mellitus \line \up0 \expndtw-7\charscalex89 Card
iac defects \line \up0 \expndtw-7\charscalex90 Ataxia \par\pard\ql \li5951\sb6\s
l-184\slmult0 \up0 \expndtw-6\charscalex100 Optic atrophy \par\pard\li1953\sb22\
sl-184\slmult0\fi0\tx4147\tx5951\tx8238 \up0 \expndtw-7\charscalex94 10.Waardenb
urg\tab \up0 \expndtw-7\charscalex94 1 to 4000 live births\tab \up0 \expndtw-7\c
harscalex94 Craniofacial anomalies\tab \up0 \expndtw-7\charscalex94 Sensorineur\
par\pard\li1953\sb16\sl-184\slmult0\fi317\tx4147\tx5951\tx8238 \up0 \expndtw-7\c
harscalex94 syndrome\tab \up0 \expndtw-7\charscalex94 2.3% of children\tab \up0
\expndtw-7\charscalex94 Multiple pigmentary\tab \up0 \expndtw-7\charscalex94 Uni
lateral\par\pard\li4305\sb16\sl-184\slmult0\fi0\tx6109 \up0 \expndtw-7\charscale
x94 with congenital\tab \up0 \expndtw-7\charscalex94 abnormalities (e.g., white\
par\pard\li4305\sb14\sl-184\slmult0\fi0\tx6109 \up0 \expndtw-7\charscalex94 hear
ing loss\tab \up0 \expndtw-7\charscalex94 forelock, partial\par\pard\ql \li6109\
sb12\sl-184\slmult0 \up0 \expndtw-7\charscalex95 albinism, early graying) \par\p
ard\qj \li1953\ri3952\sb183\sl-200\slmult0 \up0 \expndtw-6\charscalex96 Adapted
from Schaefer, G. B. (1995). Ten syndromes most commonly associated with hearing
impairment. A \up0 \expndtw-7\charscalex96 HHIRR, 2(1) .
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pbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz6\shplid0
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}}
{\shp {\*\shpinst\shpleft1953\shptop6681\shpright11796\shpbottom6701\shpfhdr0\sh
pbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(9843,20);(9843,0);(0,0)}}
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6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp {\*\shpinst\shpleft1953\shptop2945\shpright10110\shpbottom2965\shpfhdr0\sh
pbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz10\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(8157,20);(8157,0);(0,0)}}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
33}{\bkmkend Pg33}\par\pard\li3525\sb0\sl-241\slmult0\par\pard\li3525\sb0\sl-241
\slmult0\par\pard\li3525\sb201\sl-241\slmult0\fi0\tx7302 \up0 \expndtw-8\charsca
lex96 \ul0\nosupersub\cf17\f18\fs18 Overview of Disabilities\tab \up0 \expndtw-1
0\charscalex96 \ul0\nosupersub\cf14\f15\fs22 13\par\pard\qj \li1286\sb0\sl-258\s
lmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw-9\charscalex9
6 into the family is a punishment and an expression of anger from \li
ne \up0 \expndtw-10\charscalex97 oended gods and a sign of greater misfortunes to
come (Oyiborhoro, \line \up0 \expndtw-9\charscalex94 1984). In some cultures
, the Supreme Being is believed to protect \line \up0 \expndtw-10\charsca
lex97 innocent humans from every evil doer, and, furthermore, the gods are \line
\up0 \expndtw-10\charscalex96 also believed to be aware of any fetus that plans
evil from the moment \line \up0 \expndtw-9\charscalex98 of conception. Thus, to
prevent such evil plans from materializing, the \line \up0 \expndtw-7\charscale
x100 child is deformed by the gods. In certain societies from which some \line \
up0 \expndtw-9\charscalex95 new American immigrants originate, handicapped ch
ildren are either \line \up0 \expndtw-8\charscalex100 destroyed, ignored, expl
oited, or banished with their families from the \line \up0 \expndtw-9\charscalex
93 community. Some of these belief systems and cultural practices are \
line \up0 \expndtw-7\charscalex100 carried with these immigrants when they arriv
e in the United States, \line \up0 \expndtw-8\charscalex100 and they have to cop
e with reconciling an old, traditional system that \line \up0 \expndtw-6\charsca
lex100 they were used to with a new, modernized one. In some traditional \line \
up0 \expndtw-8\charscalex100 societies, religious beliefs encourage the giving a
nd taking of alms in \line \up0 \expndtw-9\charscalex92 the streets. A handic
apped child is considered a blessing, especially \line \up0 \expndtw-9\cha
rscalex93 in poverty-stricken areas, because this means the arrival of
another \line \up0 \expndtw-9\charscalex100 breadwinner for the family. The more
severe a disability is, the better, \line \up0 \expndtw-9\charscalex95 because
the disabled person will be more pitied and cared for by \line \up0 \
expndtw-10\charscalex96 sympathizers and benefactors. Sometimes the conditions o
f physically \line \up0 \expndtw-9\charscalex94 disabled children or adults
worsen or their conditions are untreated \line \up0 \expndtw-8\charscalex10
0 to embellish existing physical defects so they will look more pathetic \line \
up0 \expndtw-9\charscalex100 in the public eye. According to such a belief syste
m, the main goal of \line \up0 \expndtw-9\charscalex92 the handicapped person
is to attract as much alms as possible from \line \up0 \expndtw-10\chars
calex86 benefactors. \par\pard\qj \li1286\ri959\sb1\sl-260\slmult0\fi478 \up0 \e
xpndtw-8\charscalex100 America is a multicultural and multiethnic country compos
ed of \line \up0 \expndtw-8\charscalex100 people with diverse experiences from a
lmost every part of the world. \line \up0 \expndtw-7\charscalex100 This cultural
diversity is increasing. According to the U.S. Bureau of \line \up0 \expndtw-10
\charscalex85 Census \up0 \expndtw-10\charscalex93 (2000) about \up0 \expndtw-7
\charscalex100 80% of new immigrants who arrive in the \par\pard\qj \li12
86\ri959\sb0\sl-260\slmult0 \up0 \expndtw-5\charscalex100 United States speak
a language other than English at home. \line \up0 \expndtw-10\charscalex9
6 Audiologic assessment and aural rehabilitation plans should take into \line \
up0 \expndtw-9\charscalex100 consideration cultural backgrounds of handicapped c
hildren and their \line \up0 \expndtw-8\charscalex100 parents to achieve the des

ired goals. In taking the case history of the \line \up0 \expndtw-9\charscalex96
individual, for instance, culturally sensitive questions may need to \l
ine \up0 \expndtw-5\charscalex100 be modied to gather culturally and lingui
stically relevant data \line \up0 \expndtw-9\charscalex98 (Ballachanda, 2001).
It is important to note that the concept of disabil-\line \up0 \expndtw-10\char
scalex96 ity, hearing impairments and the handicap that they pose, acceptance, \
line \up0 \expndtw-9\charscalex97 and even rehabilitation needs vary from cultur
e to culture and also can \line \up0 \expndtw-10\charscalex97 be viewed very dier
ently.
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz87\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
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1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
34}{\bkmkend Pg34}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx3073 \up0 \expndtw-10\charsc
alex96 \ul0\nosupersub\cf14\f15\fs22 14\tab \up0 \expndtw-8\charscalex96 \ul0\no
supersub\cf17\f18\fs18 Aural Rehabilitation of People with Disabilities\par\pard
\ql \li1801\sb0\sl-276\slmult0 \par\pard\ql\li1801\sb60\sl-276\slmult0 \up0 \exp
ndtw0\charscalex103 \ul0\nosupersub\cf20\f21\fs24 MANAGEMENT OF PEOPLE WITH DISA
BILITIES \par\pard\qj \li1551\ri694\sb234\sl-264\slmult0\fi478 \up0 \expndtw-10\
charscalex94 \ul0\nosupersub\cf14\f15\fs22 Aural rehabilitation is a process des
igned to ameliorate the impact \line \up0 \expndtw-10\charscalex94 and consequen
ces of hearing impairment. For hearing-impaired people \line \up0 \expndtw-5\cha
rscalex100 without other disabilities, the goal of aural rehabilitation is prima
rily \line \up0 \expndtw-9\charscalex94 the acquisition of spoken speech and lan
guage skills. The focus of aural \line \up0 \expndtw-4\charscalex100 rehabilitat
ion is on how best to maximize the functional use of the \line \up0 \expndtw-10\
charscalex96 patient\ul0\nosupersub\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf14\f1
5\fs22 s residual hearing through use of amplication and appropriate \line \up0 \
expndtw-9\charscalex93 educational plans that facilitate and enhance learnin
g. The success of \line \up0 \expndtw-10\charscalex94 the aural-oral approach t
hat is usually used depends on the degree and \line \up0 \expndtw-9\charscalex97
onset of the hearing loss as well as early intervention (Coninx, 1995). \line
\up0 \expndtw-10\charscalex95 Rehabilitation approaches include diagnosis of the
hearing impairment, \line \up0 \expndtw-10\charscalex96 which should be accompl
ished early preferably from 0 ^12 months of \line \up0 \expndtw-6\charscalex10
0 life for the neonate and followed by early intervention through the \line \u
p0 \expndtw-10\charscalex97 provision of amplication and development of appropria
te educational \line \up0 \expndtw-9\charscalex97 plans. Early diagnosis and
intervention are recommended to take \line \up0 \expndtw-8\charscalex100 ad
vantage of the plasticity of the CNS, particularly in the rst 2 years \line \up0
\expndtw-8\charscalex100 of life when the central nervous system is considered t
o be the most \line \up0 \expndtw-10\charscalex95 sensitive (Coninx, 1995; Downs
, 1994). The tting of hearing aids and, \line \up0 \expndtw-9\charscalex95 where
necessary, the use of cochlear implants, especially by those with \line \up0 \ex
pndtw-10\charscalex96 profound hearing impairment, can facilitate and enhance de
velopment \line \up0 \expndtw-8\charscalex100 of good communication skills in he
aring-impaired individuals without \line \up0 \expndtw-9\charscalex96 other disa
bilities. The rst step toward successful and eective rehabili-\line \up0 \expndtw10\charscalex92 tation is assessment. The advent of modern electrophysiologic me
asures \line \up0 \expndtw-10\charscalex94 such as auditory brainstem response
(ABR) and otoacoustic emissions \line \up0 \expndtw-10\charscalex97 has improved

the accuracy and validity of audiologic assessment of a \line \up0 \expndtw-9\c

harscalex100 most di\u8260?cult and challenging population. Beyond evaluation,
standard \line \up0 \expndtw-9\charscalex94 and scientically validated aural
rehabilitation procedures for people \line \up0 \expndtw-9\charscalex95 with
disabilities are not available (Coninx, 1995). Several reasons have \line \up0
\expndtw-8\charscalex100 been advanced to explain this situation. Individu
als with multiple \line \up0 \expndtw-9\charscalex96 disabilities are a het
erogeneous group. As a result, it is di\u8260?cult to \line \up0 \expndt
w-9\charscalex97 realistically apply one procedure or approach to all. In additi
on, people \line \up0 \expndtw-7\charscalex100 with disabilities constitute a sm
all minority of the general population, \line \up0 \expndtw-5\charscalex100 and
it is not often cost eective to prepare and market products for \line \up0 \expnd
tw-7\charscalex100 them on a large scale. As a member of the rehabilitation te
am, the \line \up0 \expndtw-10\charscalex91 audiologist needs specic skills to be
successful (Table 1.2).
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
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\slmult0\par\pard\li3525\sb201\sl-241\slmult0\fi0\tx7304 \up0 \expndtw-8\charsca
lex96 \ul0\nosupersub\cf17\f18\fs18 Overview of Disabilities\tab \up0 \expndtw-1
0\charscalex96 \ul0\nosupersub\cf14\f15\fs22 15\par\pard\ql \li4062\sb0\sl-207\s
lmult0 \par\pard\ql\li4062\sb0\sl-207\slmult0 \par\pard\ql\li4062\sb0\sl-207\slm
ult0 \par\pard\ql\li4062\sb0\sl-207\slmult0 \par\pard\ql\li4062\sb0\sl-207\slmul
t0 \par\pard\ql\li4062\sb0\sl-207\slmult0 \par\pard\ql\li4062\sb0\sl-207\slmult0
\par\pard\ql\li4062\sb0\sl-207\slmult0 \par\pard\ql\li4062\sb0\sl-207\slmult0 \
par\pard\ql\li4062\sb0\sl-207\slmult0 \par\pard\ql\li4062\sb176\sl-207\slmult0 \
up0 \expndtw-8\charscalex93 \ul0\nosupersub\cf17\f18\fs18 Table 1.2 \par\pard\ql
\li1921\sb73\sl-207\slmult0 \up0 \expndtw-3\charscalex100 The Audiologist\ul0\n
osupersub\cf25\f26\fs18 \u8217?\ul0\nosupersub\cf17\f18\fs18 s Role as a Member
of the Rehabilitation Team \par\pard\ql \li1286\ri992\sb123\sl-220\slmult0\tx157
2\tx1572 \up0 \expndtw-7\charscalex97 The role of the audiologist as a member of
an identification team for an individual who \line\tab \up0 \expndtw0\charscale
x100 is mentally retarded and developmentally disabled includes the following \l
ine \tab \up0 \expndtw-8\charscalex93 responsibilities: \par\pard\ql \li1286\ri9
92\sb0\sl-220\slmult0\tx1669\tx1669 \up0 \expndtw-7\charscalex90 1. Assessing, d
escribing, and documenting the communicative behaviors and needs of each \line\t
ab \up0 \expndtw-7\charscalex97 client and interpreting and integrating the comm
unicative needs with educational \line \tab \up0 \expndtw-8\charscalex95 and voc
ational programming. \par\pard\ql \li1286\ri994\sb0\sl-220\slmult0\tx1711\tx1711
\up0 \expndtw-7\charscalex94 2. Evaluating various modes of communication with
reference to the individual\ul0\nosupersub\cf25\f26\fs18 \u8217?\ul0\nosupersub\
cf17\f18\fs18 s abilities, \line\tab \up0 \expndtw-7\charscalex94 disabilities,
and communication environment, to develop the most effective means \line \tab \u
p0 \expndtw-8\charscalex94 of communication possible, vocal and otherwise. \par\
pard\qj \li1286\ri994\sb0\sl-220\slmult0\tx1773 \up0 \expndtw-5\charscalex100 3.
Developing speech and vocal communication to the fullest extent possible, while
\line\tab \up0 \expndtw-7\charscalex93 focusing predominantly on the developmen
t of language rather than just speech. \par\pard\ql \li1286\ri993\sb0\sl-220\slm
ult0\tx1769\tx1769\tx1769 \up0 \expndtw-7\charscalex97 4. Developing interventio
n procedures and evaluating their effectiveness in producing \line\tab \up0 \exp

ndtw-7\charscalex96 systems of communication that meet the demands of the enviro

nment; interface \line \tab \up0 \expndtw-5\charscalex100 with other programming
; and are appropriate to educational, vocational, and \line \tab \up0 \expndtw-8
\charscalex89 social settings. \par\pard\ql \li1286\ri994\sb0\sl-220\slmult0\tx1
762\tx1762 \up0 \expndtw-7\charscalex95 5. Incorporating within assessment and i
ntervention program procedures the significant \line\tab \up0 \expndtw-7\charsca
lex100 others in the life of the mentally retarded individual including direct c
aregivers, \line \tab \up0 \expndtw-8\charscalex92 family members, employers, an
d other professional team members. \par\pard\qj \li1286\ri993\sb0\sl-220\slmult0
\tx1781 \up0 \expndtw-7\charscalex96 6. Where necessary, training persons to int
eract with the mentally retarded person who \line\tab \up0 \expndtw-8\charscalex
91 uses an augmentative system of communication. \par\pard\qj \li1286\ri994\sb17
\sl-200\slmult0\tx1787 \up0 \expndtw-7\charscalex95 7. Being a client advocate f
or audiologic services including diagnostic and rehabilitative \line\tab \up0 \e
xpndtw-8\charscalex85 services. \par\pard\li1286\sb0\sl-184\slmult0\par\pard\li1
286\sb33\sl-184\slmult0\fi0 \up0 \expndtw-6\charscalex96 \ul0\nosupersub\cf22\f2
3\fs16 American Speech-Language-Hearing Association. (1982). Serving the c
ommunicatively handi-\par\pard\li1286\sb15\sl-184\slmult0\fi0\tx4439\tx4871\tx5
514 \up0 \expndtw-7\charscalex95 capped mentally retarded individual. ASHA,\
tab \up0 \expndtw-7\charscalex83 24(8),\tab \up0 \expndtw-7\charscalex87 547^553
.\tab \up0 \expndtw-7\charscalex95 (Copyright by the American\par\pard\li1286
\sb16\sl-184\slmult0\fi0 \up0 \expndtw-7\charscalex95 Speech-Language-Hearing As
sociation. Reprinted with permission.)
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
36}{\bkmkend Pg36}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253

\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx3073 \up0 \expndtw-10\charsc

alex96 \ul0\nosupersub\cf14\f15\fs22 16\tab \up0 \expndtw-8\charscalex96 \ul0\no
supersub\cf17\f18\fs18 Aural Rehabilitation of People with Disabilities\par\pard
\ql \li2468\sb0\sl-276\slmult0 \par\pard\ql\li2468\sb60\sl-276\slmult0 \up0 \exp
ndtw0\charscalex103 \ul0\nosupersub\cf20\f21\fs24 PEOPLE WITH OTHER DISABILITIES
\par\pard\qj \li1551\ri694\sb235\sl-263\slmult0\fi478 \up0 \expndtw-10\charscal
ex97 \ul0\nosupersub\cf14\f15\fs22 Unlike for hearing-impaired people without ad
ditional handicaps, \line \up0 \expndtw-8\charscalex100 for hearing-impaired ind
ividuals with other disabilities such as mental \line \up0 \expndtw-9\charscalex
97 retardation, visual impairment, CP, and autism the goals of aural \l
ine \up0 \expndtw-8\charscalex100 rehabilitation may vary. The extent to which f
unctional residual hear-\line \up0 \expndtw-6\charscalex100 ing can be maximized
does not depend solely on the degree of the \line \up0 \expndtw-9\charscalex96
hearing impairment but more so on the extent, degree, or impact \line
\up0 \expndtw-9\charscalex100 of other dominant or multiple existing handicaps t
hat may be present. \line \up0 \expndtw-8\charscalex100 For individuals with mu
ltiple disabilities, such as mental retardation, \line \up0 \expndtw-9\charsca
lex95 learning disabilities, and visual impairments, who are also unable t
o \line \up0 \expndtw-10\charscalex100 acquire language skills, aural rehabilita
tion goals need to be modied \line \up0 \expndtw-10\charscalex96 (Coninx, 1995) f
or the appropriate levels of development and function-\line \up0 \expndtw-4\char
scalex100 ing of the individual. The goal of aural rehabilitation for this group
\line \up0 \expndtw-5\charscalex100 of individuals is not necessarily or
primarily the acquisition of \line \up0 \expndtw-10\charscalex89 spoken langu
age. \par\pard\qj \li1551\ri697\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charsc
alex100 Ramsdell (1977) described dierent levels of hearing from which \line \up0
\expndtw-8\charscalex100 rehabilitation goals for people with disabilities coul
d be derived. They \line \up0 \expndtw-9\charscalex96 are as follows: (1) basic
level, (2) signal level, (3) symbolic level, and \par\pard\ql \li1551\sb6\sl253\slmult0 \up0 \expndtw-10\charscalex90 (4) sensomotoric feedback level. \par\
pard\ql \li2030\ri694\sb118\sl-264\slmult0\tx2276\tx2276\tx2276\tx2276\tx2276 \u
p0 \expndtw-10\charscalex95 1. Basic level of hearing. Hearing is important at
this level for the \line\tab \up0 \expndtw-5\charscalex100 individual to bond wi
th the environment without the feeling \line \tab \up0 \expndtw-10\charscalex96
of being alone in a silent world. The individual is able to detect \line \tab \u
p0 \expndtw-10\charscalex96 environmental sounds; hearing at this level provides
a state of \line \tab \up0 \expndtw-10\charscalex92 awareness about the existen
ce of dierent kinds of sounds in the \line \tab \up0 \expndtw-10\charscalex93 env
ironment and their eects. \par\pard\ql \li2030\ri695\sb0\sl-265\slmult0\tx2285\tx
2285\tx2285\tx2285 \up0 \expndtw-10\charscalex95 2. Signal level of hearing. Th
e individual is able to recognize and \line\tab \up0 \expndtw-10\charscalex94 di
scriminate between various sounds that are important for \line \tab \up0
\expndtw-10\charscalex96 daily living. For instance, the individual is able to a
ttach mean-\line \tab \up0 \expndtw-10\charscalex94 ing to alerting sounds such
as re alarms, sirens, or honks that \line \tab \up0 \expndtw-10\charscalex93 may
signify danger. \par\pard\ql \li2030\ri694\sb0\sl-260\slmult0\tx2273\tx2273 \up0
\expndtw-9\charscalex88 3. Symbolic level of hearing. This represents the high
est level of listen-\line\tab \up0 \expndtw-10\charscalex96 ing skills in that
it involves linguistic processing of abstract \line \tab \up0 \expndtw-10\c
harscalex92 sounds and understanding of spoken words. \par\pard\ql \li2030\ri694
\sb0\sl-270\slmult0\tx2285\tx2285 \up0 \expndtw-9\charscalex89 4. Sensomotoric
feedback level of hearing. Unlike at the basic, signal, \line\tab \up0 \expndtw9\charscalex100 and symbolic levels of hearing, which require receptive skills,
\line \tab \up0 \expndtw-10\charscalex91 at the sensomotoric level, skills
are needed to control gross
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\li6541\sb0\sl-207\slmult0 \par\pard\ql\li6541\sb0\sl-207\slmult0 \par\pard\ql\l
i6541\sb0\sl-207\slmult0 \par\pard\ql\li6541\sb101\sl-207\slmult0 \up0 \expndtw8\charscalex93 \ul0\nosupersub\cf17\f18\fs18 Table 1.3 \par\pard\ql \li4422\sb73
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f People with Disab \par\pard\li1953\sb0\sl-207\slmult0\par\pard\li1953\sb143\sl
-207\slmult0\fi0\tx3904\tx6504 \up0 \expndtw-8\charscalex94 Levels of hearing\ta
b \up0 \expndtw-8\charscalex94 Nature of sounds\tab \up0 \expndtw-8\charscalex94
Aural rehabilitation goals\par\pard\li1953\sb80\sl-207\slmult0\fi0\tx3707\tx585
2 \up0 \expndtw-8\charscalex94 Basic\tab \up0 \expndtw-8\charscalex94 Environmen
tal sounds\tab \up0 \expndtw-8\charscalex94 Reduce individual isolation\par\pard
\li3707\sb12\sl-207\slmult0\fi0\tx5852 \up0 \expndtw-8\charscalex96 Traffic nois
e\tab \up0 \expndtw-8\charscalex96 Facilitate and enhance bonding with the\par\p
ard\li3707\sb13\sl-207\slmult0\fi0\tx6031 \up0 \expndtw-8\charscalex96 Music\tab
\up0 \expndtw-8\charscalex96 environment\par\pard\li3707\sb11\sl-207\slmult0\fi
0\tx5852 \up0 \expndtw-8\charscalex96 Bell ringing\tab \up0 \expndtw-8\charscale
x96 Enlarge and enrich the limited world of\par\pard\ql \li6031\sb12\sl-207\slmu
lt0 \up0 \expndtw-8\charscalex96 the deaf-blind \par\pard\ql \li5852\sb1\sl-198\
slmult0 \up0 \expndtw-8\charscalex91 Increase the activity level \par\pard\qj \l
i5852\ri3974\sb4\sl-220\slmult0\fi179 \up0 \expndtw-8\charscalex90 (state of aro
usal) of passive individuals \up0 \expndtw-8\charscalex96 Create an environment
for the individual t \up0 \expndtw-8\charscalex91 experience and enjoy music \pa
r\pard\li1953\sb28\sl-207\slmult0\fi0\tx3707\tx5852 \up0 \expndtw-8\charscalex94
Signal\tab \up0 \expndtw-8\charscalex94 Warning signals\tab \up0 \expndtw-8\cha
rscalex94 Develop an alerting and warning\par\pard\li3707\sb11\sl-207\slmult0\fi
0\tx6031 \up0 \expndtw-8\charscalex90 Fire alarms\tab \up0 \expndtw-8\charscalex
90 sound signal system\par\pard\li3707\sb12\sl-207\slmult0\fi0\tx5852 \up0 \expn
dtw-8\charscalex90 Siren\tab \up0 \expndtw-8\charscalex90 Increase the individua
l\ul0\nosupersub\cf25\f26\fs18 \u8217?\ul0\nosupersub\cf17\f18\fs18 s state of a
rousal\par\pard\li3707\sb13\sl-207\slmult0\fi0\tx5852 \up0 \expndtw-8\charscalex
90 Train/car horns\tab \up0 \expndtw-8\charscalex90 Encourage the use of nonverb
al sounds as\par\pard\li1952\sb12\sl-207\slmult0\fi4078 \up0 \expndtw-8\charscal
ex93 referential objects\par\pard\li1952\sb12\sl-207\slmult0\fi0\tx3707\tx5852 \
up0 \expndtw-8\charscalex93 Symbolic\tab \up0 \expndtw-8\charscalex93 Meaning of
words\tab \up0 \expndtw-8\charscalex93 Stimulate, encourage, and reinforce\par\
pard\li1952\sb13\sl-207\slmult0\fi4078 \up0 \expndtw-8\charscalex92 voicing for
demands/requests\par\pard\li1952\sb12\sl-207\slmult0\fi0\tx3707\tx5852 \up0 \exp
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ab \up0 \expndtw-8\charscalex92 Reduce and discourage unwanted\par\pard\li1952\s
b12\sl-207\slmult0\fi0\tx3707\tx6031 \up0 \expndtw-8\charscalex92 Feedback\tab \
up0 \expndtw-8\charscalex92 Speech production\tab \up0 \expndtw-8\charscalex92 a
nd socially unacceptable voicing\par\pard\li3707\sb11\sl-207\slmult0\fi0\tx5852
\up0 \expndtw-8\charscalex91 Receptive speech\tab \up0 \expndtw-8\charscalex91 F
acilitate cognitive development\par\pard\li3707\sb13\sl-207\slmult0\fi0\tx6031 \
up0 \expndtw-8\charscalex91 Expressive speech\tab \up0 \expndtw-8\charscalex91 t
hrough various learning tasks\par\pard\qj \li1953\ri3841\sb171\sl-200\slmult0 \u
p0 \expndtw-5\charscalex100 \ul0\nosupersub\cf22\f23\fs16 Adapted from Coninx, F
. (1995). Aural rehabilitation issues with multiply handicapped hearing-impaired
chi \line \up0 \expndtw-6\charscalex95 61^ 65; and Ramsdell, D. (1977). The psy
chology of the hard of hearing and deafened adult. In Silverman, D.
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\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx3074 \up0 \expndtw-10\charsc
alex96 \ul0\nosupersub\cf14\f15\fs22 18\tab \up0 \expndtw-8\charscalex96 \ul0\no
supersub\cf17\f18\fs18 Aural Rehabilitation of People with Disabilities\par\pard
\qj \li2285\sb0\sl-240\slmult0 \par\pard\qj\li2285\ri695\sb106\sl-240\slmult0 \u
p0 \expndtw-10\charscalex96 \ul0\nosupersub\cf14\f15\fs22 and ne motor activities
and to manage speech production for \line \up0 \expndtw-10\charscalex97 phonati
on and articulation \up0 \expndtw-10\charscalex94 (Coninx, 1995). For peopl
e with \par\pard\qj \li2285\ri695\sb4\sl-260\slmult0 \up0 \expndtw-10\charscale
x95 severe disabilities aural rehabilitation at the symbolic level is \up0 \e
xpndtw-10\charscalex95 di\u8260?cult to achieve, because it requires receptive a
nd expressive \up0 \expndtw-10\charscalex90 speech and language skills. Howe
ver, as Coninx (1995) sug\up0 \expndtw-10\charscalex92 gested, attempts to a
chieve this level should not be neglected or \up0 \expndtw-10\charscalex94 ignor
ed. Instead, there should be individualized goals to reect \up0 \expndtw-10\char
scalex95 the individual\ul0\nosupersub\cf19\f20\fs22 \u8217?\ul0\nosupersub\cf14
\f15\fs22 s level of development and degree and impact of \up0 \expndtw-10\chars
calex95 disability. Some examples of goals derived at dierent levels of \up0 \exp
ndtw-10\charscalex88 hearing are displayed in Table 1.3. \par\pard\ql \li3842\sb
0\sl-276\slmult0 \par\pard\ql\li3842\sb51\sl-276\slmult0 \up0 \expndtw-3\charsca
lex100 \ul0\nosupersub\cf20\f21\fs24 REFERENCES \par\pard\qj \li1551\sb0\sl-220\
slmult0 \par\pard\qj\li1551\ri729\sb71\sl-220\slmult0\tx1790 \up0 \expndtw-7\cha
rscalex87 \ul0\nosupersub\cf17\f18\fs18 American Psychiatric Association. (1994)
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up0 \expndtw-7\charscalex96 (1991). Preschool visually impaired children: A
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ult0\tx1790 \up0 \expndtw-7\charscalex88 Cherow, E. (Ed.). (1985). Hearing-impai
red children and youth with developmental disabilities. \line\tab \up0 \expndtw8\charscalex88 Washington, DC: Gallaudet College Press. \par\pard\qj \li1551\ri7
29\sb0\sl-220\slmult0\tx1790 \up0 \expndtw-7\charscalex97 Coninx, F. (1995).
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p0 \expndtw-8\charscalex87 impaired children. Scandinavian Audiology Supplement,
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\slmult0\par\pard\li3525\sb201\sl-241\slmult0\fi0\tx7307 \up0 \expndtw-8\charsca
lex96 \ul0\nosupersub\cf17\f18\fs18 Overview of Disabilities\tab \up0 \expndtw-1
0\charscalex96 \ul0\nosupersub\cf14\f15\fs22 19\par\pard\ql \li1286\sb0\sl-207\s
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ndtw-8\charscalex84 American Family Physician, 57(8), 1813 ^1822. \par\pard\ql \
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w-8\charscalex94 Kayser, H. \tab \up0 \expndtw-7\charscalex96 (1998). Outcomes
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\up0 \expndtw-7\charscalex96 Kramer, L. C., Sullivan, R. F., & Hirsch, L. M. (19
79). Audiological evaluation and aural \line\tab \up0 \expndtw-7\charscalex94 re
habilitation of the deaf-blind adult. New York: Helen Keller National Cen
ter for \line \tab \up0 \expndtw-8\charscalex94 Deaf-Blind Youths and Adults. \
par\pard\ql \li1551\ri728\sb0\sl-220\slmult0\tx1790\tx1790\tx1790\tx1790 \up0 \e
xpndtw-3\charscalex100 Mallory, B. L., Charlton, J. I., Nicholls, R. W., & Marfo
, K. (1993). Traditional and \line\tab \up0 \expndtw-7\charscalex95 changing vi
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\tab \up0 \expndtw-7\charscalex92 cautions. The International Exchange of E
xperts and Information in Rehabilitation \line \tab \up0 \expndtw-6\charscal
ex100 Monograph 53. Durham, NH: International Exchange of Experts and Informatio
n \line \tab \up0 \expndtw-6\charscalex100 in Rehabilitation. \par\pard\qj \li15
51\ri728\sb0\sl-220\slmult0\tx1790 \up0 \expndtw-7\charscalex92 Mencher, G. T.,
& Gerber, S. E. (Eds.). (1983). The multiply handicapped hearing impaired \line\
tab \up0 \expndtw-8\charscalex92 child. New York: Grune & Stratton. \par\pard\li
1551\sb1\sl-207\slmult0\fi0\tx2822 \up0 \expndtw-8\charscalex95 Mutua, N. K.\t
ab \up0 \expndtw-8\charscalex95 (2001). Importance of parent\ul0\nosupersub\c
f25\f26\fs18 \u8217?\ul0\nosupersub\cf17\f18\fs18 s expectations and beliefs
in the\par\pard\li1551\sb12\sl-207\slmult0\fi239 \up0 \expndtw-7\charscalex96
educational participation of children with mental retardation in Kenya. Educatio
n\par\pard\li1551\sb12\sl-207\slmult0\fi239 \up0 \expndtw-7\charscalex96 andTrai
ning in Mental Retardation and Developmental Disabilities, 36, 148 ^159.\par\par
d\li1551\sb11\sl-207\slmult0\fi0 \up0 \expndtw-7\charscalex96 U.S. Census Bureau
. (2000a). Table 5: Language spoken at home for the foreign-born\par\pard\li1551
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ulation\tab \up0 \expndtw-8\charscalex95 5\tab \up0 \expndtw-8\charscalex93 year
s and over:\tab \up0 \expndtw-8\charscalex95 1980 ^1990. Washington, DC: U.S
. Government\par\pard\li1551\sb12\sl-207\slmult0\fi239 \up0 \expndtw-8\charscal
ex95 Printing O\u8260?ce.\par\pard\qj \li1551\ri730\sb0\sl-220\slmult0\tx1790 \u
p0 \expndtw-7\charscalex98 U.S. Department of Education, O\u8260?ce of Edu
cational Research and Improvement \line\tab \up0 \expndtw-8\charscalex89 (200
0). Digest of education statistics (p. 65).Washington, DC: Author. \par\pard\qj
\li1551\ri729\sb0\sl-220\slmult0\tx1790 \up0 \expndtw-7\charscalex91 U.S. Depart
ment of Justice. (1991). Americans with Disabilities Act handbook. Washington, \
line\tab \up0 \expndtw-8\charscalex91 DC: U.S. Government Printing O\u8260?ce. \
par\pard\ql \li1551\sb1\sl-204\slmult0\tx3944 \up0 \expndtw-4\charscalex100 Wein
stein, B., & Amstel, L. \tab \up0 \expndtw-7\charscalex100 (1986). Hearing
loss and senile dementia in the \par\pard\ql \li1790\sb14\sl-207\slmult0 \
up0 \expndtw-8\charscalex90 institutionalized elderly. Clinical Gerontologist, 4
(3), 3 ^15. \par\pard\qj \li1551\ri728\sb3\sl-220\slmult0\tx1790 \up0 \expndtw-7
\charscalex100 World Health Organization. (1998). ICIDH-2 Beta 1 Field Tr
ials. Retrieved from \line\tab \up0 \expndtw-7\charscalex100 http://www.who.or
g.
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0\nosupersub\cf2\f3\fs22 John M.A. Oyiborhoro, Ed.D., F.A.A.A., CCC-A \par\pard\
ql \li3471\ri3176\sb0\sl-240\slmult0\tx3804 \up0 \expndtw-4\charscalex100 \ul0\n
osupersub\cf6\f7\fs20 Boro Audiology Clinic \line\tab \up0 \expndtw-4\charscalex
100 Brooklyn, NY \par\pard\ql \li4250\sb7\sl-230\slmult0 \up0 \expndtw-9\charsca
lex92 and \par\pard\ql \li2581\sb10\sl-230\slmult0 \up0 \expndtw-8\charscalex100
National Institute for People with Disabilities \par\pard\ql \li3780\sb10\sl-23
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-230\slmult0 \par\pard\ql\li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb110\sl
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3319\ri3112\sb2\sl-240\slmult0 \up0 \expndtw-9\charscalex95 Background/Case Hist
ory \up0 \expndtw-9\charscalex96 Otoscopy \par\pard\ql \li3319\sb9\sl-230\slmult
0 \up0 \expndtw-9\charscalex100 PureTone Audiometry \par\pard\qj \li3319\ri2241\
sb2\sl-240\slmult0 \up0 \expndtw-9\charscalex100 Conventional PureTone Audiometr
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\charscalex100 Visual Reinforcement Audiometry \up0 \expndtw-9\charscalex100 Air
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xpndtw-9\charscalex93 Electrophysiologic Measures \line \up0 \expndtw-3\charscal
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ar\pard\ql \li2840\sb1\sl-217\slmult0 \up0 \expndtw-8\charscalex100 References \
par\pard\ql \li2840\sb13\sl-230\slmult0 \up0 \expndtw-7\charscalex100 Selected R
eadings \par\pard\ql \li4312\sb0\sl-207\slmult0 \par\pard\ql\li4312\sb0\sl-207\s
lmult0 \par\pard\ql\li4312\sb0\sl-207\slmult0 \par\pard\ql\li4312\sb0\sl-207\slm
ult0 \par\pard\ql\li4312\sb0\sl-207\slmult0 \par\pard\ql\li4312\sb194\sl-207\slm
ult0 \up0 \expndtw-8\charscalex87 \ul0\nosupersub\cf5\f6\fs18 23 \par\pard\qj \l
i3067\ri2882\sb0\sl-160\slmult0\fi65 \up0 \expndtw0\charscalex100 \ul0\nosupersu
b\cf30\f31\fs12 Aural Rehabilitation for People with Disabilities \line \up0 \ex
pndtw0\charscalex100 Copyright \up0 \expndtw-2\charscalex100 2005, Elsevier Inc.
All rights reserved.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
44}{\bkmkend Pg44}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2859 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 24\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\ql \li2030\sb0\sl-253\slmult0 \par\pard\ql\li2030\sb82\sl-253\slmult0\tx3484
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 Cerebral palsy \tab \
up0 \expndtw-10\charscalex96 (CP) is not a disease; rather it represents
a \par\pard\qj \li1551\ri694\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex95 s
ymptom complex and is an umbrella term used to encompass a group \line \up0 \exp
ndtw-9\charscalex95 of nonprogressive but often changing disorders of motor func
tion result-\line \up0 \expndtw-8\charscalex100 ing from brain injury or malform
ation (Kuban & Leviton, 1994; Mutch \line \up0 \expndtw-9\charscalex90 et al., 1
992). Brain lesions that cause various disorders may also contribute \line \up0
\expndtw-9\charscalex98 to other problems including, but not limited to, m
ental retardation, \line \up0 \expndtw-9\charscalex89 seizures, speech and lang
uage disorders, and vision and hearing disorders, \line \up0 \expndtw-9\charscal
ex91 which are often associated with CP. These other handicaps are also called \
line \up0 \expndtw-9\charscalex89 developmental disabilities. They may be severe
or chronic and may occur in \line \up0 \expndtw-9\charscalex93 an individual at
5 years of age or older but must be manifested before the \line \up0 \expndtw-9
\charscalex98 individual attains the age of 22 to qualify as developmental disab
ilities \line \up0 \expndtw-9\charscalex94 (Developmental Disabilities Assistanc

e and Bill of Rights Act, 1990). Our \line \up0 \expndtw-9\charscalex92 denition
of CP (especially the causes that are also related to those of the \line \up0 \e
xpndtw-9\charscalex95 other disabilities) deserves clarication because CP serves
as our main \line \up0 \expndtw-8\charscalex100 disability, along with which oth
er handicaps will be grouped together \line \up0 \expndtw-10\charscalex87 later.
\par\pard\qj \li1551\ri695\sb0\sl-257\slmult0\fi478 \up0 \expndtw-6\charscalex1
00 Many cases of CP result from several types of pre-, peri-, and \line \up0 \ex
pndtw-10\charscalex88 postnatal events \up0 \expndtw-10\charscalex91 (Evenhuis,
1996; Molnar, 1985; Nelson & Ellenberg, \line \up0 \expndtw-9\charscalex8
8 1978; Pharoah, 1989). Prenatal events, for instance, may be due to maternal \l
ine \up0 \expndtw-9\charscalex94 infection (such as rubella, cytomegalovirus, t
oxoplasmosis, herpes, and \line \up0 \expndtw-9\charscalex94 syphilis), drug and
alcohol use during pregnancy, maternal disease, pla-\line \up0 \expndtw-9\chars
calex95 cental insu\u8260?ciency, and severe circulatory and cardiovascular prob
lems. \line \up0 \expndtw-6\charscalex100 Perinatal injuries occur during birth
and may result from prolonged \line \up0 \expndtw-10\charscalex94 labor, umbil
ical cord compression \up0 \expndtw-10\charscalex92 (which often causes ano
xia), and \par\pard\qj \li1551\ri696\sb0\sl-260\slmult0 \up0 \expndtw-9\charsca
lex96 head trauma. Postnatal events, on the other hand, occur after birth and \u
p0 \expndtw-9\charscalex96 may include, but are not limited to, infection
s such as meningitis, \up0 \expndtw-9\charscalex95 head injuries sustained fr
om accidental childhood falls, cerebrovascular \up0 \expndtw-9\charscalex92 acci
dents, and blood diseases. However, CP does not include motor \up0 \expn
dtw-9\charscalex96 disorders resulting from head injuries or cerebrovascular acc
idents that \up0 \expndtw-10\charscalex96 occur much later in life. \par\pard\qj
\li1551\ri695\sb0\sl-260\slmult0\fi478 \up0 \expndtw-8\charscalex100 CP is clas
sied according to the parts of the body aected. For \line \up0 \expndtw-7\charscal
ex100 instance, in monoplegia, only one limb is aected on one side of the \line \
up0 \expndtw-7\charscalex100 body; in diplegia, legs are mostly aected with a mil
d muscle tone in \line \up0 \expndtw-9\charscalex96 the upper body; and in hemip
legia, one side of the body is aected with \line \up0 \expndtw-8\charscalex100 th
e arm being more aected than the legs, trunk, or face. The arm is \line \up0 \exp
ndtw-8\charscalex100 generally bent at the hand, wrist, or elbow with an associa
ted loss of \line \up0 \expndtw-10\charscalex93 sensation in about 50% of patien
ts (Nelson & Ellenberg, 1978; Pharoah, \line \up0 \expndtw-9\charscalex92 1989).
In quadriplegia, all four limbs, that is, arms and legs, as well as the
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
45}{\bkmkend Pg45}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7292 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 25\par\pard\qj \li1286
\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw9\charscalex93 trunk are involved. CP may also be classied according to the locat
ion of \line \up0 \expndtw-9\charscalex98 the brain lesion. For example, in spas
tic (pyramidal) CP, the condition \line \up0 \expndtw-6\charscalex100 is due to
damage to the cerebrum, which controls the initiation and \line \up0 \expndtw-10
\charscalex96 coordination of voluntary body movements (Kuban and Leviton, 1994)
. \line \up0 \expndtw-9\charscalex97 If the cerebrum is injured, the integ
rity of the pyramidal tracts is \line \up0 \expndtw-7\charscalex100 comprom

ised. The pyramidal tracts unite the motor cortex with \line \up0 \expnd
tw-9\charscalex100 eerent nerve bers that relay motor signals to the muscles to co
ntrol \line \up0 \expndtw-9\charscalex94 voluntary movement of body parts.
Spastic CP is considered to be \line \up0 \expndtw-9\charscalex97 the most
common type of CP. It is characterized by very limited \line \up0 \ex
pndtw-9\charscalex95 movement and stiness. Choreoathetoid (extrapyramidal) C
P is an-\line \up0 \expndtw-9\charscalex98 other type, which is also refe
rred to as athetosis. This condition \line \up0 \expndtw-10\charscalex96 re
sults from damage to the cerebellum or basal ganglia, which causes \line \up0 \e
xpndtw-9\charscalex94 abnormal movements of body parts. Thus athetosis is
characterized \line \up0 \expndtw-10\charscalex96 by involuntary and purposeles
s movement of the head, arms, ngers, \line \up0 \expndtw-9\charscalex93 legs, a
nd trunk, as well as communication problems. Ataxia is also \line \up0
\expndtw-6\charscalex100 another condition that is due to an insult to the cereb
ellum, and it is \line \up0 \expndtw-9\charscalex100 characterized by an unst
eady gait and uncoordinated and shaky \line \up0 \expndtw-8\charscalex100 m
ovement. If more than one condition occurs in the same individual, \line \up0 \e
xpndtw-9\charscalex98 such as quadriplegia in an individual with spastic athetos
is, it is called \line \up0 \expndtw-10\charscalex93 mixed CP (Molnar, 1985). \p
ar\pard\qj \li1286\ri960\sb4\sl-256\slmult0\fi478 \up0 \expndtw-10\charscalex90
The incidence of moderate to severe cases of CP is estimated \line \up
0 \expndtw-10\charscalex95 to be between 1.5 and 2.5 per 1000 live births (Kuban
& Levton, 1994). \line \up0 \expndtw-9\charscalex94 The estimated prevalence
of developmental disabilities ranges from \line \up0 \expndtw-10\charscalex
94 1 to 2% (American Speech-Language and Hearing Association, 1989). \line \up
0 \expndtw-7\charscalex100 On the other hand, the prevalence of hearing-impaired
children with \line \up0 \expndtw-9\charscalex97 CP or other developmental
disabilities may vary widely. Reported \line \up0 \expndtw-10\charscalex91 e
stimates range from \up0 \expndtw-10\charscalex97 5 to \up0 \expndtw-10\chars
calex90 59% (Fisch, 1957; Gersh, 1991; Lloyd & \par\pard\qj \li1286\ri959\
sb1\sl-260\slmult0 \up0 \expndtw-10\charscalex92 Moore, 1972; Nakano, 1966; Oyib
orhoro, 1993; Pruszewicz et al., 1977). \line \up0 \expndtw-9\charscalex96 Subje
ct selection, subject age, and the denition of what constitutes \line \up0 \
expndtw-9\charscalex96 a hearing loss may in part explain the wide variability i
n the prevalence \line \up0 \expndtw-6\charscalex100 of hearing impairment in
individuals with CP or developmental \line \up0 \expndtw-9\charscalex94 di
sabilities ( Levine, 1971; Lloyd & Moore, 1972). W|th subject selection, \line \
up0 \expndtw-9\charscalex95 for instance, studies indicate that individuals
with Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s sy
ndrome \line \up0 \expndtw-9\charscalex93 have a hearing loss prevalence tw
o to four times greater than that \line \up0 \expndtw-8\charscalex100 for
others with other types of disabilities (Dahle & McCollister, 1986). \line \up0
\expndtw-7\charscalex100 Generally, the lower the criterion for what constitutes
a hearing loss \line \up0 \expndtw-4\charscalex100 and the lower the cognitive
level and functioning of the individual, \line \up0 \expndtw-9\charscalex100 the
greater the prevalence of hearing impairment among people with
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
46}{\bkmkend Pg46}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2859 \up0 \expndtw-10\charsc

alex97 \ul0\nosupersub\cf2\f3\fs22 26\tab \up0 \expndtw-8\charscalex97 \ul0\nosu

persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-258\slmult0 \par\pard\qj\li1551\ri695\sb73\sl-258\slmult0 \
up0 \expndtw-9\charscalex94 \ul0\nosupersub\cf2\f3\fs22 disabilities (Ray, 2002;
Van Schrojenstein Lantman-DeValk et al., 1994). \line \up0 \expndtw-8\charscale
x100 As previously noted, many individuals with CP also have other \lin
e \up0 \expndtw-9\charscalex93 associated disabilities. Hur (1997) reports that
about 40 ^ 60% of children \line \up0 \expndtw-9\charscalex95 with CP have an in
tellectual disability, 50% have seizure disorders, and \line \up0 \expndtw-9\cha
rscalex93 20 ^ 60% have visual defects, perceptual dysfunction, communicat
ion \line \up0 \expndtw-9\charscalex93 disorders, behavior problems, social mala
djustment, and hearing decits. \line \up0 \expndtw-6\charscalex100 It is well kno
wn that many of the causes of CP, mental retardation, \line \up0 \expndtw-9\char
scalex93 and other developmental disabilities, such as anoxia, meningitis, cytom
e-\line \up0 \expndtw-9\charscalex92 galovirus infection, rubella, and toxop
lasmosis, have been associated \line \up0 \expndtw-10\charscalex93 with heari
ng impairment as well (Bess & Humes, 1990; Evenhuis, 1996). \line \up0 \expndtw8\charscalex100 Some individuals with CP have normal or near-normal cognition an
d \line \up0 \expndtw-9\charscalex93 do not have other developmental disabilitie
s. There is also another group \line \up0 \expndtw-9\charscalex92 of individuals
with severe and mixed CP, who have associated disabilities \line \up0 \expndtw8\charscalex100 (with varying degrees of severity) that interfere with a
ctivities of \line \up0 \expndtw-10\charscalex94 everyday living. \par\pard\qj
\li1551\ri696\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91 Both group
s are referred to as consumers. The term consumer \line \up0 \expndtw-7\c
harscalex100 as used here means individuals with CP and/or developmental
\line \up0 \expndtw-6\charscalex100 disabilities. Use of this term removes
the negative connotation \line \up0 \expndtw-9\charscalex98 often associate
d with disabilities such as CP, mental retardation, \line \up0 \expndtw-9
\charscalex94 Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs
22 s syndrome, and autism as well as others. The term is used \line \u
p0 \expndtw-9\charscalex96 interchangeably to refer to either people with
CP or developmental \line \up0 \expndtw-8\charscalex100 disabilities or both
as necessary. Because CP is not a disease, \line \up0 \expndtw-10\charsc
alex91 several techniques have been used to \up0 \expndtw-10\charscalex95 (
re)habilitate this population. \par\pard\qj \li1551\ri697\sb0\sl-260\slmult0 \
up0 \expndtw-9\charscalex95 These methods include the use of surgery to
correct some of the \line \up0 \expndtw-9\charscalex95 physical deformities a
nd the use of prostheses, drugs, physical therapy, \line \up0 \expndtw-9\charsca
lex92 speech therapy, and audiologic rehabilitation to ameliorate the challenges
\line \up0 \expndtw-9\charscalex98 presented by CP itself as well as oth
er associated handicapping \line \up0 \expndtw-10\charscalex93 conditions. \pa
r\pard\qj \li1551\ri694\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 A
udiologic evaluation of the physically challenged consumer is \line \up0 \
expndtw-9\charscalex94 particularly challenging. Too often, a lack of response t
o acoustic signals \line \up0 \expndtw-9\charscalex93 is misinterpreted to mean
a hearing loss, even when a hearing loss is not \line \up0 \expndtw-10\charscale
x95 present (Sigenenthler, 1987). In the population with Down\ul0\nosupersub\cf
11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s syndrome \line \up0 \expndtw-7\
charscalex100 peripheral hearing impairment is not only more prevalent, but thes
e \line \up0 \expndtw-10\charscalex95 consumers also have di\u8260?culty storing
and retrieving processed informa-\line \up0 \expndtw-9\charscalex93 tion (Swif
& Rosin, 1988). The standard behavioral audiologic test battery \line \up0 \expn
dtw-10\charscalex93 composed of pure tone and speech audiometry requires that th
e individ-\line \up0 \expndtw-9\charscalex93 ual must respond either verbally (e
.g., saying\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\f
s22 yes\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 )
or by the\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs
22 raising\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs2
2 of \line \up0 \expndtw-9\charscalex93 a hand when the presented sound signal

is heard or by correctly pointing

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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
47}{\bkmkend Pg47}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7292 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 27\par\pard\ql \li1286
\sb0\sl-258\slmult0 \par\pard\ql\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw9\charscalex96 to identify a picture. These response tasks are not suitable for
the non-\line \up0 \expndtw-9\charscalex92 verbal, severely physically challenge
d consumer with CP because of their \line \up0 \expndtw-9\charscalex97 limited n
euromuscular and cognitive abilities. Unfortunately, audiologic \line \up0 \expn
dtw-9\charscalex92 assessment techniques and guidelines for this population are
limited. The \line \up0 \expndtw-10\charscalex91 use of electrophysiologic measu
res has been strongly suggested by some \line \up0 \expndtw-10\charscalex97 rese
archers and clinicians. However, despite the introduction of these \line \up0 \e
xpndtw-10\charscalex94 objective measures in recent years, conventional behavior
al audiometry \line \up0 \expndtw-9\charscalex95 continues to be widely used
among audiologists in the challenging \line \up0 \expndtw-10\charscalex93
evaluation of consumers with CP. Although electrophysiologic measures \line \up0
\expndtw-9\charscalex91 such as auditory brainstem response (ABR), otoacoustic
emissions (OAE), \line \up0 \expndtw-9\charscalex96 and immittance can demonstra
te the integrity of the auditory structures \line \up0 \expndtw-10\charscalex97
and pathways, only behavioral measures can reveal their actual func-\line \up0 \
expndtw-5\charscalex100 tional utility in communication. Furthermore, ABR, which
has been \line \up0 \expndtw-9\charscalex94 an accepted practice for more than
2 decades, has pitfalls, with reported \line \up0 \expndtw-9\charscalex93 instan
ces of misdiagnosis (Worthington & Peters, 1980). As the reliability \line \up0
\expndtw-10\charscalex95 of some of the results from ABR particularly for spec
ial populations \line \up0 \expndtw-9\charscalex91 come to question, behavioral
measures have continued to serve as simple, \line \up0 \expndtw-9\charscalex98 e
\u8260?cient, cost-eective, and essential clinical tools in hearing evaluation \l
ine \up0 \expndtw-10\charscalex96 of consumers (Cornacchia et al., 1982; Diefe
ndorf, 2002; Lancioni & \line \up0 \expndtw-10\charscalex90 Coninx, 1989). \par
\pard\qj \li1286\ri959\sb2\sl-258\slmult0\fi478 \up0 \expndtw-8\charscalex100 Ov
er the years, clinicians have been compelled to improvise or \line \up0 \expndtw
-9\charscalex94 adapt the traditional audiologic test battery for the evaluation
of severely \line \up0 \expndtw-10\charscalex93 physically challenged consumers
. For some consumers, important basic \line \up0 \expndtw-10\charscalex92 behavi
oral test components such as speech audiometry have often been \line \up0 \expnd
tw-10\charscalex94 ignored. Because people do not communicate in pure tones, it
is impor-\line \up0 \expndtw-9\charscalex95 tant to examine other ways, for inst
ance, of assessing speech reception \line \up0 \expndtw-9\charscalex93 abilities
especially of nonverbal, physically challenged consumers. In \line \up0
\expndtw-10\charscalex96 addition, because of the heterogeneity of the populatio
n, standard and \line \up0 \expndtw-9\charscalex100 uniform evaluation methods a
re di\u8260?cult to establish. In the absence of \line \up0 \expndtw-10\charscal
ex96 established methods, some clinicians have used word identication by \line \u
p0 \expndtw-9\charscalex100 appropriate pointing to the correct pictorial repres
entation. The use of \line \up0 \expndtw-10\charscalex93 this point-to-response

mode, although sometimes suitable for assessing \line \up0 \expndtw-8\charscalex

100 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 norm
al\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 indiv
iduals, is probably unrealistic for evaluation of severely \line \up0 \expndtw-9
\charscalex94 handicapped consumers.We will return to this subject later in the
speech \line \up0 \expndtw-10\charscalex94 audiometry section of this chapter. \
par\pard\qj \li1286\ri961\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91
In this chapter materials and methods used in the assessment \line \up
0 \expndtw-9\charscalex94 and management of severely physically challenged,
hearing-impaired \line \up0 \expndtw-10\charscalex94 consumers (with CP and/or
developmental disabilities) are examined.
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
48}{\bkmkend Pg48}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2859 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 28\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-240\slmult0 \par\pard\qj\li1551\ri698\sb106\sl-240\slmult0
\up0 \expndtw-9\charscalex92 \ul0\nosupersub\cf2\f3\fs22 Professional encounters
with consumers demand that the clinician should \up0 \expndtw-10\charscalex87 p
ossess some specic skills as shown in Table 2.1. \par\pard\ql \li3020\sb0\sl-276\
slmult0 \par\pard\ql\li3020\sb255\sl-276\slmult0 \up0 \expndtw0\charscalex103 \u
l0\nosupersub\cf7\f8\fs24 AUDIOLOGIC EVALUATION \par\pard\ql \li3254\sb0\sl-207\
slmult0 \par\pard\ql\li3254\sb94\sl-207\slmult0 \up0 \expndtw0\charscalex102 B\u
l0\nosupersub\cf31\f32\fs17 ACKGROUND\ul0\nosupersub\cf7\f8\fs24 /C\ul0\nosupers
ub\cf31\f32\fs17 ASE\ul0\nosupersub\cf7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17
ISTORY \par\pard\qj \li1551\sb0\sl-258\slmult0 \par\pard\qj\li1551\ri693\sb13\sl
-258\slmult0\fi478 \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 The
rst step in audiologic evaluation of a person with disabilities \line \up0 \expn
dtw-9\charscalex95 is the taking of a complete case history. The case history is
both critical \line \up0 \expndtw-9\charscalex95 and useful in many respects. F
irst, the process creates the initial oppor-\line \up0 \expndtw-3\charscalex100
tunity for the clinician to interact directly and closely with the con-\line \up
0 \expndtw-8\charscalex100 sumer and the family member or the signicant other acc
ompanying \line \up0 \expndtw-10\charscalex97 the individual for the evaluation.
Second, a rapport with the consumer \line \up0 \expndtw-9\charscalex94 and the
signicant other is established more easily and may prove \line \up0 \ex
pndtw-5\charscalex100 useful during the actual evaluation. Third, it enables the
clinician to \line \up0 \expndtw-9\charscalex100 form a mental hypothesis about
the nature and possible extent of the \line \up0 \expndtw-9\charscalex97 proble
m. Fourth, the clinician is able to gain a better insight into \line
\up0 \expndtw-9\charscalex94 the status of the consumer\ul0\nosupersub\cf11\f12\
fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s general health and mental well-being.
Fifth, \line \up0 \expndtw-10\charscalex97 the knowledge gained helps in the cho
ice of appropriate test batteries \line \up0 \expndtw-10\charscalex97 and protoc
ols to enable the evaluation to be conducted more e\u8260?ciently \line \up0 \ex
pndtw-5\charscalex100 and eectively. Choice of the wrong protocols may be attribu
ted to \line \up0 \expndtw-9\charscalex95 incomplete or inadequate case history
taking. This may lead to misdiag-\line \up0 \expndtw-9\charscalex94 nosis and
wrong or inappropriate management. Case history taking \line \up0 \expndtw

-9\charscalex94 should encompass the following areas: audiologic background

check, \line \up0 \expndtw-10\charscalex94 communication skills, and medical ba
ckground (see Appendix at end of \line \up0 \expndtw-10\charscalex90 this chapte
r). \par\pard\ql \li3182\sb0\sl-253\slmult0 \par\pard\ql\li3182\sb134\sl-253\slm
ult0 \up0 \expndtw-2\charscalex100 Audiologic Background Check \par\pard\qj \li1
551\ri694\sb122\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 Determining
development levels of the consumer is necessary \line \up0 \expndtw-10\cha
rscalex93 and knowing the consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosu
persub\cf2\f3\fs22 s chronologic and mental ages is essential in \line \up0 \exp
ndtw-7\charscalex100 the choice of methods of testing, test protocols, and inter
pretation of \line \up0 \expndtw-9\charscalex92 audiologic ndings after evaluatio
n has been completed. Assessment of a \line \up0 \expndtw-9\charscalex92 30 -yea
r-old consumer who has a mental age of a toddler warrants use of \line \up0 \exp
ndtw-9\charscalex92 age-appropriate test methods and interpretation of audiologi
c outcomes. \par\pard\qj \li1551\ri695\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10
\charscalex96 Sometimes the consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\no
supersub\cf2\f3\fs22 s legal name on paper may be dierent \line \up0 \expndtw-10\
charscalex97 from the name he or she is called at home, and the individual may
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz97\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
49}{\bkmkend Pg49}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7290 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 29\par\pard\ql \li4059
\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\s
b0\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb0
\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb124
\sl-207\slmult0 \up0 \expndtw-8\charscalex94 \ul0\nosupersub\cf5\f6\fs18 Table 2
.1 \par\pard\qj \li1751\ri1463\sb63\sl-220\slmult0 \up0 \expndtw-3\charscalex100
Knowledge Areas/Skills an Audiologist Must PossessWhenWorking \line \up0 \expnd
tw-3\charscalex100 with Mentally Retarded/Developmentally Disabled Individuals \
par\pard\ql \li1286\ri995\sb120\sl-220\slmult0\tx1466\tx1466 \up0 \expndtw-7\cha
rscalex91 To meet the standards established by the Code of Ethics, the speech-la
nguage pathologist \line\tab \up0 \expndtw-7\charscalex95 and the audiologist wh
o provide communication services to mentally retarded \line \tab \up0 \expndtw-8
\charscalex93 individuals should possess the following: \par\pard\ql \li1286\sb7
1\sl-207\slmult0\tx1492 \up0 \expndtw-8\charscalex81 1. \tab \up0 \expndtw-7\cha
rscalex97 Knowledge concerning mentally retarded individuals, including informat
ion about \par\pard\ql \li1466\sb13\sl-207\slmult0 \up0 \expndtw-7\charscalex95
a. factors that contribute to communicative disorders and method of prevention,
\par\pard\ql \li1466\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex92 b. preve
rbal development, \par\pard\ql \li1466\sb13\sl-207\slmult0 \up0 \expndtw-8\chars
calex92 c. augmentative communication systems, \par\pard\ql \li1466\sb13\sl-207
\slmult0 \up0 \expndtw-8\charscalex92 d. prognosis, and \par\pard\ql \li1466\sb
13\sl-207\slmult0 \up0 \expndtw-8\charscalex90 e. therapeutic techniques. \par\
pard\ql \li1286\sb13\sl-207\slmult0\tx1481 \up0 \expndtw-8\charscalex86 2. \tab
\up0 \expndtw-7\charscalex95 The ability to deal with a variety of handicapping
conditions (i.e., aberrant behavior, \par\pard\qj \li1678\ri995\sb3\sl-220\slmul
t0 \up0 \expndtw-7\charscalex92 seizures, feeding problems, etc.) that are evide
nced by mentally retarded individuals \up0 \expndtw-8\charscalex92 in addition t

o the communication disorder. \par\pard\ql \li1286\sb11\sl-207\slmult0\tx1490 \u

p0 \expndtw-8\charscalex80 3. \tab \up0 \expndtw-7\charscalex94 Expertise in ong
oing diagnosis and assessment (through formal and informal, \par\pard\ql \li1286
\ri994\sb3\sl-220\slmult0\fi383\tx1669\tx1678\tx1678\tx1671 \up0 \expndtw-7\char
scalex92 standardized and nonstandardized procedures) of the type, nature, and s
everity \line\tab \up0 \expndtw-8\charscalex93 of the communication disorder evi
denced by a mentally retarded person. \line \up0 \expndtw-8\charscalex86 4. \up
0 \expndtw-7\charscalex97 The knowledge required to plan and implement an interv
ention program that will \line\tab \up0 \expndtw-7\charscalex96 allow the mental
ly retarded individual to develop communication skills, vocal or \line \tab \up0
\expndtw-7\charscalex95 otherwise, that are appropriate to the individual\ul0\n
osupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s living environment
and potential. \line \up0 \expndtw-8\charscalex81 5. \up0 \expndtw-7\charscalex
95 Skill in cooperating in an interdisciplinary team approach to provide service
s in the \line\tab \up0 \expndtw-8\charscalex95 clinical, educational, or living
milieu of the retarded person. \par\pard\ql \li1286\sb11\sl-207\slmult0\tx1479
\up0 \expndtw-8\charscalex85 6. \tab \up0 \expndtw-7\charscalex92 The ability to
educate colleagues, administrators, parents, direct care staff, and the \par\pa
rd\ql \li1286\ri1124\sb7\sl-215\slmult0\fi391\tx1677\tx1677\tx1667 \up0 \expndtw
-7\charscalex96 community about mentally retarded individuals and their communic
ation needs. \line\tab \up0 \expndtw-7\charscalex95 This includes the ability to
conduct staff training, establish home programs, \line \tab \up0 \expndtw-7\cha
rscalex93 and involve paraprofessionals to meet the needs of mentally retarded i
ndividuals. \line \up0 \expndtw-8\charscalex78 7. \up0 \expndtw-7\charscalex95
Insight into knowledge and techniques of other professions that deal with mental
ly \line\tab \up0 \expndtw-8\charscalex90 retarded people. \par\pard\li1286\sb0\
sl-184\slmult0\par\pard\li1286\sb28\sl-184\slmult0\fi0 \up0 \expndtw-6\charscale
x97 \ul0\nosupersub\cf3\f4\fs16 American Speech-Language-Hearing Association
(1982). Serving the communicatively handi-\par\pard\li1286\sb15\sl-184\slmul
t0\fi0\tx4522\tx4808\tx5466 \up0 \expndtw-7\charscalex96 capped mentally retar
ded individual. ASHA,\tab \up0 \expndtw-7\charscalex81 24,\tab \up0 \expndtw-7
\charscalex87 547^553.\tab \up0 \expndtw-7\charscalex96 (Copyright by the Ame
rican\par\pard\li1286\sb16\sl-184\slmult0\fi0 \up0 \expndtw-7\charscalex96 Speec
h-Language-Hearing Association. Reprinted with permission.)
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1286\shptop9240\shpright7503\shpbottom9260\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp

bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz96\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
50}{\bkmkend Pg50}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2857 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 30\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri694\sb70\sl-260\slmult0 \
up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 become unresponsive whe
n the legal name is called. If the consumer is \up0 \expndtw-9\charscalex93 more
used to his or her nickname, it is usually better to use this preferred \up0 \e
xpndtw-9\charscalex92 name. Use of the preferred name tends to facilitate bondin
g and to create \up0 \expndtw-10\charscalex92 a good rapport with the consumer.
\par\pard\qj \li1551\ri694\sb0\sl-264\slmult0\fi478 \up0 \expndtw-9\charscalex10
0 To obtain information about the hearing status of the consumer, \line \up0 \ex
pndtw-9\charscalex96 parents should be asked the following questions: Is there a
ny history of \line \up0 \expndtw-9\charscalex93 hearing loss in your family? Do
you suspect that your child has a hearing \line \up0 \expndtw-9\charscalex93 lo
ss? Has your child ever used a hearing aid before? The clinician should \line \u
p0 \expndtw-10\charscalex93 be aware that all answers may be negative, because p
arents of children \line \up0 \expndtw-10\charscalex94 with CP and other disabil
ities may not be prepared to receive more bad \line \up0 \expndtw-9\charscalex98
news about an additional disability they have to cope with if this is the \line
\up0 \expndtw-10\charscalex94 rst audiologic appointment or an appointment to ob
tain a second opin-\line \up0 \expndtw-9\charscalex94 ion on the hearing status
of their child. If, for instance, a parent suspects \line \up0 \expndtw-9\charsc
alex100 the presence of a hearing loss, he or she may be more receptive and \lin
e \up0 \expndtw-9\charscalex92 cooperative during counseling. A possible\ul0\nos
upersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 honest\ul0\nosu
persub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 answer helps the
clini-\line \up0 \expndtw-8\charscalex100 cian in forming a mental hypothesis ab
out what is going on auditorily \line \up0 \expndtw-9\charscalex95 and narrowing
the choice of the test battery to be used. If a parent says \line \up0 \expndtw
-8\charscalex100 that there is no history of hearing loss in the family or that
the child is \line \up0 \expndtw-9\charscalex94 not suspected of having a hearin
g problem, but he or she states that the \line \up0 \expndtw-9\charscalex100 chi
ld was wearing hearing aids until they were lost a few months ago, \line \up0 \e
xpndtw-7\charscalex100 this inconsistency signals a red ag for the clinician. Pr
obing further \line \up0 \expndtw-9\charscalex95 about the type of hearing aid,
length of time the device was used before \line \up0 \expndtw-9\charscalex93 bei
ng lost, and results of previous evaluations may provide a better \line
\up0 \expndtw-10\charscalex93 understanding about the nature and extent of hear
ing loss. \par\pard\ql \li3584\sb0\sl-253\slmult0 \par\pard\ql\li3584\sb250\sl-2
53\slmult0 \up0 \expndtw0\charscalex100 Communication Skills \par\pard\qj \li155
1\ri694\sb118\sl-264\slmult0\fi478 \up0 \expndtw-8\charscalex100 The clinician n
eeds to know the predominant language that the \line \up0 \expndtw-10\charscalex
95 consumer is exposed to at home or at the residence, if the consumer is \line
\up0 \expndtw-9\charscalex90 institutionalized. Many consumers can receive a mis
diagnosis because of a \line \up0 \expndtw-9\charscalex92 language barrier. If t
he consumer does not understand the necessary test \line \up0 \expndtw-9\charsca
lex96 instructions clearly before an evaluation, it is likely that appropriate a
nd \line \up0 \expndtw-9\charscalex93 expected responses may not be obtained. In
this case, there is a need to \line \up0 \expndtw-9\charscalex96 provide an int

erpreter for the consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf

2\f3\fs22 s native language to be certain \line \up0 \expndtw-9\charscalex97 tha
t test instructions are properly understood and also to help address \line \up0
\expndtw-9\charscalex97 issues arising from previous evaluations. If, for exampl
e, a consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s
\line \up0 \expndtw-10\charscalex97 primary or predominant language at home is S
panish or Russian, it
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
51}{\bkmkend Pg51}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7304 \up0 \expndtw-8\charsca
lex92 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 31\par\pard\ql \li1286
\sb0\sl-258\slmult0 \par\pard\ql\li1286\ri961\sb45\sl-258\slmult0\tx1764 \up0 \e
xpndtw-9\charscalex95 would be more appropriate to use this language to give tes
t instructions \line \up0 \expndtw-10\charscalex93 and to provide audiologic cou
nseling after the test is completed. \line \tab \up0 \expndtw-10\charscalex96 Do
younger consumers recognize the voices of their parents? Or \line \up0 \expndtw
-9\charscalex96 can older consumers dierentiate the voices of their close caregiv
ers or \line \up0 \expndtw-9\charscalex95 support sta ? What are their reacti
ons to loud sounds? People with \line \up0 \expndtw-10\charscalex97 autism ar
e known to have unusual auditory decits (Konstantareas & \line \up0 \expndtw-9\c
harscalex98 Homatidis, 1987; Schlopler, Reichler, DeVellis, & Daly, 1980). Autis
tic \line \up0 \expndtw-10\charscalex95 consumers often show inconsistent respon
ses to acoustic stimuli. They \line \up0 \expndtw-10\charscalex96 are usually un
responsive to human voices and often avoid making any \line \up0 \expndtw-9\char
scalex93 direct eye contact. Consumers with autistic features are hypersensitive
to \line \up0 \expndtw-10\charscalex92 sounds (McCormick, 1995) and may make qu
ick responses to loud\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersu
b\cf2\f3\fs22 non-\line \up0 \expndtw-9\charscalex89 sense\ul0\nosupersub\cf11\f
12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 or mechanical sounds, especial
ly if such sounds are presented when \line \up0 \expndtw-10\charscalex89 the con
sumer is in a calm and undistracted state. \par\pard\qj \li1286\ri959\sb1\sl-260
\slmult0\fi478 \up0 \expndtw-10\charscalex92 Does the consumer respond to his or
her name if the caller is out of \line \up0 \expndtw-8\charscalex100 visual eld
? Does the consumer respond or is the consumer able to \line \up0 \expndtw-10\ch
arscalex97 identify a conventional telephone ring, doorbell, or smoke alarm? Has
\line \up0 \expndtw-10\charscalex94 the consumer worn an amplication device befo
re? If the answer is yes, \line \up0 \expndtw-10\charscalex95 was the consumer s
atised with the device(s)? Many consumers reject \line \up0 \expndtw-9\charscalex
100 hearing devices because of overtting. Overtting may originate from \line \up0
\expndtw-10\charscalex91 inappropriate selection of devices based on \up0 \
expndtw-10\charscalex91 awed test results. One \par\pard\qj \li1286\ri959\sb0\
sl-260\slmult0 \up0 \expndtw-10\charscalex97 additional question is: Can the con
sumer verbalize any words or obey \up0 \expndtw-10\charscalex92 commands? The an
swers to these questions may give an insight into the \up0 \expndtw-10\charscale
x93 presence, nature, and extent of a hearing impairment. \par\pard\ql \li3398\s
b0\sl-253\slmult0 \par\pard\ql\li3398\sb133\sl-253\slmult0 \up0 \expndtw-2\chars
calex100 Medical Background \par\pard\qj \li1286\ri961\sb122\sl-260\slmult0\fi47
8 \up0 \expndtw-9\charscalex100 Information about specic medical conditions is ob

tained at this \line \up0 \expndtw-6\charscalex100 time. Questions to ask includ

e the following. Are there any obvious \line \up0 \expndtw-9\charscalex93 cranio
facial anomalies? What specic disabilities or syndromes are pres-\line \up0 \expn
dtw-10\charscalex93 ent? Refer to the list of top 10 \up0 \expndtw-10\cha
rscalex91 syndromes associated with hearing \par\pard\qj \li1286\ri959\sb0\sl
-260\slmult0 \up0 \expndtw-10\charscalex95 impairment in Chapter 1. Do some of t
hese syndromes have an impact \line \up0 \expndtw-9\charscalex93 on the auditory
system? Were there any maternal diseases or pre-, peri-, \line \up0 \expndtw-8\
charscalex100 or postnatal events during the consumer\ul0\nosupersub\cf11\f
12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s birth? If there was a \line \u
p0 \expndtw-8\charscalex100 period of hospitalization, what was the length of ho
spital stay and the \line \up0 \expndtw-6\charscalex100 type of medication taken
by the consumer (or the mother during or \line \up0 \expndtw-8\charscalex100 a
fter delivery)? Were any of the drugs used known to be ototoxic? \line \up0 \
expndtw-8\charscalex100 The mental age of the person is important in se
lecting the test \line \up0 \expndtw-10\charscalex96 battery components and in
choosing the test protocols. For instance, a
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
52}{\bkmkend Pg52}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2854 \up0 \expndtw-10\charsc
alex96 \ul0\nosupersub\cf2\f3\fs22 32\tab \up0 \expndtw-8\charscalex96 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-262\slmult0 \par\pard\qj\li1551\ri694\sb66\sl-262\slmult0 \
up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 30 -year-old adult with
a mental age of a 2-year-old obviously needs a \line \up0 \expndtw-9\charscalex
96 test mode and interpretation dierent from those used for a normal 30 -\line \u
p0 \expndtw-6\charscalex100 year-old adult. Does the individual have a history o
f ear infection? If \line \up0 \expndtw-9\charscalex95 hearing loss is present f
rom a previous evaluation, what type of hearing \line \up0 \expndtw-10\charscale
x96 loss was present? Does the consumer have limited visual acuity? The \line \u
p0 \expndtw-8\charscalex100 extent of the consumer\ul0\nosupersub\cf11\f12\fs22
\u8217?\ul0\nosupersub\cf2\f3\fs22 s vision limitation will dictate how much mod
-\line \up0 \expndtw-10\charscalex96 ication should be made if visual reinforceme
nt audiometry (VRA) has \line \up0 \expndtw-9\charscalex90 been selected as a te
chnique to use during evaluation. A good case history \line \up0 \expndtw-8\char
scalex100 of the consumer provides an invaluable initial step in the choice
of \line \up0 \expndtw-9\charscalex96 appropriate test batteries and test prot
ocols before evaluation. W|th a \line \up0 \expndtw-9\charscalex96 knowledge of
the dominant disability (or associated disabilities), mental \line \up0 \expndt
w-9\charscalex96 age, and communication and motor skills, the clinician is able
to form a \line \up0 \expndtw-10\charscalex95 mental hypothesis of the degree, t
ype, and conguration of the hearing \line \up0 \expndtw-9\charscalex100 loss. The
clinician should have an idea about the nal outcome of the \line \up0 \expndtw-1
0\charscalex90 evaluation based on the case history before proceeding. \par\pard
\ql \li3240\sb0\sl-253\slmult0 \par\pard\ql\li3240\sb253\sl-253\slmult0 \up0 \ex
pndtw-1\charscalex100 Other Consumer Information \par\pard\qj \li1551\ri695\sb11
8\sl-265\slmult0\fi478 \up0 \expndtw-9\charscalex100 Ask the person who accompan
ied the consumer for information \line \up0 \expndtw-6\charscalex100 about the
nature of their relationship. That is, is the person a direct \line \up0 \expndt

w-8\charscalex100 caregiver or blood relation? This information will determine t

he kinds \line \up0 \expndtw-9\charscalex94 of questions the clinician should as
k to take into consideration the sensi-\line \up0 \expndtw-9\charscalex93 tiviti
es of and/or perceptions of the accompanying person, especially if he \line \up0
\expndtw-9\charscalex93 or she is the consumer\ul0\nosupersub\cf11\f12\fs22 \u8
217?\ul0\nosupersub\cf2\f3\fs22 s parent. Creating a good rapport with the accom
-\line \up0 \expndtw-9\charscalex91 panying parents or direct caregivers is almo
st as important as creating and \line \up0 \expndtw-9\charscalex95 maintaining a
good rapport with the consumer for four reasons: (1) they \line \up0 \expndtw-9
\charscalex95 can become the clinician\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\
nosupersub\cf2\f3\fs22 s friend and partner in the evaluation process, \par\pard
\qj \li1551\ri694\sb0\sl-264\slmult0 \up0 \expndtw-8\charscalex100 (2) they can
provide more detailed information about the consumer\ul0\nosupersub\cf11\f12\fs2
2 \u8217?\ul0\nosupersub\cf2\f3\fs22 s \line \up0 \expndtw-5\charscalex100 likes
and dislikes that are likely to interfere with or compromise test \line \up0 \e
xpndtw-10\charscalex96 results but that are not usually adequately recorded in t
he consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s \l
ine \up0 \expndtw-10\charscalex91 chart; \up0 \expndtw-10\charscalex90 (3) main
taining their presence can reassure the consumer that \line \up0 \expndtw
-9\charscalex94 he or she is in safe and familiar territory because there
is someone \line \up0 \expndtw-9\charscalex95 familiar who can calm fears; an
d (4) they can provide information about \line \up0 \expndtw-7\charscalex100 the
types of medications the consumer is taking and dosages. \line \up0 \e
xpndtw-9\charscalex95 Accompanying persons can also provide information as
to whether \line \up0 \expndtw-9\charscalex93 the consumer is in a happy, sad
, angry, or sick (worse than usual) mode. \line \up0 \expndtw-9\charscalex93 Thi
s information alone can help the clinician decide whether to suspend
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz83\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
53}{\bkmkend Pg53}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7294 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 33\par\pard\qj \li1286
\sb0\sl-240\slmult0 \par\pard\qj\li1286\ri961\sb78\sl-240\slmult0 \up0 \expndtw8\charscalex100 or cancel the session or determine how to cope with the consumer
\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s \up0 \expndtw
-10\charscalex94 emotional mode. \par\pard\ql \li3882\sb0\sl-207\slmult0 \par\pa
rd\ql\li3882\sb0\sl-207\slmult0 \par\pard\ql\li3882\sb154\sl-207\slmult0 \up0 \e
xpndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 O\ul0\nosupersub\cf31\f32\fs1
7 TOSCOPY \par\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri959\sb10
\sl-260\slmult0\fi478 \up0 \expndtw-9\charscalex96 \ul0\nosupersub\cf2\f3\fs22 A
fter history taking, the next step in the evaluation process is \line \up
0 \expndtw-9\charscalex97 otoscopic examination. This involves a visual inspecti
on of the ear and \line \up0 \expndtw-9\charscalex93 ear canal. W|th the advent
of video otoscopy, this procedure has become \line \up0 \expndtw-7\charscalex100
more exciting and fun for the consumer, accompanying caregiver or \line \up0 \e
xpndtw-8\charscalex100 parent, and the clinician. First, the pinna and external
auditory canals \line \up0 \expndtw-9\charscalex93 are examined for any structur
al abnormalities that may reveal features of \line \up0 \expndtw-9\charscalex98
syndromes known to be associated with hearing impairment. \line \u

p0 \expndtw-6\charscalex100 Abnormally small or missing pinna and stenotic or mi

ssing external \line \up0 \expndtw-10\charscalex97 auditory canals are some of t
he structural ear defects associated with \line \up0 \expndtw-10\charscalex96 sy
ndromes such as Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\
fs22 s, Treacher Collin, and Alport\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nos
upersub\cf2\f3\fs22 s. These syn-\line \up0 \expndtw-10\charscalex93 dromes are
associated with a high incidence of hearing impairment. The \line \up0 \expndtw10\charscalex94 clinician should check for impacted or excessive cerumen accumul
ation \line \up0 \expndtw-9\charscalex95 in the ear canal, which is a frequent a
nd chronic problem in this popula-\line \up0 \expndtw-10\charscalex93 tion (Cran
dell & Roeser, 1993; Evenhuis, 1995) and a common cause of \line \up0 \expndtw-9
\charscalex92 conductive hearing loss. The incidence of impacted/excessive cerum
en in \line \up0 \expndtw-9\charscalex96 this population is much higher tha
n that in the general population \line \up0 \expndtw-9\charscalex91 (Evenhu
is, 1995). Ray (2002) provided three reasons for this occurrence: \par\pard\ql \
li1764\ri960\sb120\sl-260\slmult0\tx2010\tx2010 \up0 \expndtw-10\charscalex96 1.
Consumers tend to have anatomic ear dierences such as the \line\tab \up0 \expnd
tw-10\charscalex90 stenotic \up0 \expndtw-10\charscalex93 (narrowing) ear cana
ls seen in Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs
22 s syndromes, \line \tab \up0 \expndtw-10\charscalex94 which tend to facilita
te cerumen accumulation. \par\pard\ql \li1764\ri961\sb0\sl-260\slmult0\tx2019\tx
2019 \up0 \expndtw-10\charscalex97 2. Physiologic dierences on how cerumen is
produced among \line\tab \up0 \expndtw-10\charscalex97 consumers and the gene
ral population coupled with poor \line \tab \up0 \expndtw-10\charscalex89 hy
giene. \par\pard\ql \li1764\sb6\sl-253\slmult0\tx4498 \up0 \expndtw-10\charscale
x96 3. Inability of the consumer \tab \up0 \expndtw-10\charscalex93 (because
of cognitive decits) to \par\pard\qj \li2008\ri962\sb2\sl-260\slmult0 \up0 \
expndtw-10\charscalex96 complain about ear discomfort and hearing loss resulting
from \up0 \expndtw-10\charscalex92 impacted cerumen. \par\pard\qj \li1286\ri959
\sb120\sl-260\slmult0 \up0 \expndtw-9\charscalex97 An additional reason that
might be added is the lack of annual or \up0 \expndtw-9\charscalex96 perio
dic audiologic services to help maintain better hearing health \up0 \exp
ndtw-9\charscalex93 for these consumers. Thus periodic audiologic evaluatio
ns should be \up0 \expndtw-10\charscalex95 recommended for these consumers and
appropriate referrals made for \up0 \expndtw-10\charscalex91 cerumen management
.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
54}{\bkmkend Pg54}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2857 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 34\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-258\slmult0 \par\pard\qj\li1551\ri695\sb73\sl-258\slmult0\f
i478 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 The ear canal
is further examined for canal drainage and \line \up0 \expndtw-10\charscal
ex95 integrity of the tympanic membrane. V|deo otoscopy makes this visual-\line
\up0 \expndtw-9\charscalex97 ization easier, and the consumer is often exited
about seeing\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3
\fs22 inside \line \up0 \expndtw-9\charscalex93 the ear,\ul0\nosupersub\cf11\f12
\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 which may create more interest

in subsequent procedures. W|th \line \up0 \expndtw-10\charscalex95 video otoscop

y, both the consumer and the accompanying caregiver or \line \up0 \expndtw-9\cha
rscalex94 family member can visualize the ear canal together to exclude excessiv
e \line \up0 \expndtw-10\charscalex94 cerumen accumulation or the presence of a
foreign body. Some consu-\line \up0 \expndtw-9\charscalex94 mers do not want the
ir ears touched and may vigorously resist otoscopic \line \up0 \expndtw-9\charsc
alex95 examination. It is not advisable for the clinician to push too far, becau
se \line \up0 \expndtw-10\charscalex92 the consumer\ul0\nosupersub\cf11\f12\fs22
\u8217?\ul0\nosupersub\cf2\f3\fs22 s resistance may be hardened by such action,
thereby dis-\line \up0 \expndtw-9\charscalex96 couraging further participatio
n in subsequent procedures. Although \line \up0 \expndtw-10\charscalex95 imm
ittance measurements should normally follow otoscopy, we will \line \up0 \
expndtw-7\charscalex100 discuss these later in the physiologic testing section.
Otherwise, it is \line \up0 \expndtw-10\charscalex96 good to check the status of
the middle ear immediately after otoscopy. \line \up0 \expndtw-9\charscalex100
However, some consumers, particularly children, resist the use of the \line \up0
\expndtw-10\charscalex97 probe tip as in immittance measurements. Again, it is
not advisable to \line \up0 \expndtw-9\charscalex95 force the issue, but rather
to return to the procedure after speech audio-\line \up0 \expndtw-10\charscalex9
1 metry has been completed. \par\pard\ql \li3403\sb0\sl-207\slmult0 \par\pard\ql
\li3403\sb0\sl-207\slmult0 \par\pard\ql\li3403\sb151\sl-207\slmult0 \up0 \expndt
w0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 P\ul0\nosupersub\cf31\f32\fs17 URE\
ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupersub\cf31\f32\fs17 ONE\ul0\nosupersub\cf
7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UDIOMETRY \par\pard\qj \li1551\sb0\sl258\slmult0 \par\pard\qj\li1551\ri694\sb13\sl-258\slmult0\fi478 \up0 \expndtw-6\
charscalex100 \ul0\nosupersub\cf2\f3\fs22 Some consumers with CP or other disabi
lities, who have mild \line \up0 \expndtw-9\charscalex94 disabilities or nearnormal developmental conditions, do not present \line \up0 \expndtw-10\char
scalex96 many di\u8260?culties in testing. Such consumers can be evaluated using
the \line \up0 \expndtw-9\charscalex95 conventional methods that are applicable
to the general population. The \line \up0 \expndtw-7\charscalex100 audiometric
ndings for consumers with CP in particular may show \line \up0 \expndtw-7\charsc
alex100 some similarities in terms of conguration and symmetry of hearing \line \
up0 \expndtw-9\charscalex94 impairment, mostly in the high-frequency range
(Mysak, 1971; Ray, \line \up0 \expndtw-10\charscalex96 2002). In pure tone au
diometry, the objective always is to use conven-\line \up0 \expndtw-9\charscalex
94 tional methods and protocols to obtain accurate hearing thresholds. \
line \up0 \expndtw-7\charscalex100 Although this is possible for consumers with
mild disabilities or near-\line \up0 \expndtw-9\charscalex95 normal developmenta
l conditions, it is not a realistic goal for consumers \line \up0 \expndtw-10\ch
arscalex93 who are nonverbal or who have severe to profound neurologic, physical
, \line \up0 \expndtw-9\charscalex94 motor, and cognitive decits. The primary and
realistic goal in this group \line \up0 \expndtw-8\charscalex100 of consumers,
therefore, is to rule out bilateral moderate to profound \line \up0 \expndtw-10\
charscalex92 hearing loss, especially in the speech frequencies of \up0 \
expndtw-10\charscalex88 500 ^2000 \up0 \expndtw-8\charscalex100 Hz \par\pard\ql
\li1551\sb7\sl-253\slmult0 \up0 \expndtw-10\charscalex86 (Gans & Gans, 1993; Sie
genthaler, 1987).
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz99\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg

55}{\bkmkend Pg55}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7298 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 35\par\pard\qj \li1286
\sb0\sl-256\slmult0 \par\pard\qj\li1286\ri959\sb49\sl-256\slmult0\fi478 \up0 \ex
pndtw-10\charscalex95 Involuntary body movements are very common in the CP popul
a-\line \up0 \expndtw-9\charscalex100 tion with spastic athetosis. If these move
ments become vigorous and \line \up0 \expndtw-6\charscalex100 prolonged, they ma
y interfere with testing. Such rhythmic, vigorous \line \up0 \expndtw-10\charsca
lex95 body movements may create masking noise in the 30 ^ 40 dB range \line
\up0 \expndtw-10\charscalex91 (Mysak, 1971), which may compromise test result ac
curacy. Furthermore, \line \up0 \expndtw-10\charscalex96 concentration and respo
nses to the primary auditory pure tone signals \line \up0 \expndtw-10\charscalex
97 being presented become di\u8260?cult for the consumer to attend to. \par\pard
\ql \li2349\sb0\sl-207\slmult0 \par\pard\ql\li2349\sb0\sl-207\slmult0 \par\pard\
ql\li2349\sb151\sl-207\slmult0 \up0 \expndtw0\charscalex106 \ul0\nosupersub\cf7\
f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 ONVENTIONAL\ul0\nosupersub\cf7\f8\fs24 P
\ul0\nosupersub\cf31\f32\fs17 URE\ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupersub\c
f31\f32\fs17 ONE\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UDIO
METRY \par\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri959\sb10\sl260\slmult0\fi478 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 For
consumers with higher cognitive levels who do not have seri-\line \up0 \expndtw8\charscalex100 ous additional disabilities, conventional pure tone audiometry c
an be \line \up0 \expndtw-10\charscalex95 performed. This procedure involves pr
esenting pure tone signals and \line \up0 \expndtw-10\charscalex97 having the
consumer respond whenever the signal is heard by saying \line \up0 \expndtw-7\ch
arscalex100 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\f
s22 yes,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22
raising a hand, or pushing a button. Our preference is to ask \line \up0 \expnd
tw-9\charscalex93 consumers to say\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\
ul0\nosupersub\cf2\f3\fs22 yes\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\n
osupersub\cf2\f3\fs22 each time the signal is heard because this keeps \line \u
p0 \expndtw-8\charscalex100 them more alert and focused on the task. Some consum
ers prefer to \line \up0 \expndtw-9\charscalex94 describe the loudness or softne
ss of the tones, which is also acceptable. \line \up0 \expndtw-10\charscalex95 T
he use of insert earphones is encouraged and advocated. Figure 2.1 \line \up0 \
expndtw-10\charscalex94 shows a consumer being prepared by a clinician for an ev
aluation using \line \up0 \expndtw-10\charscalex88 insert earphones. \par\pard\q
j \li1286\ri959\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex94 Insert ea
rphones are disposable and can help in maintaining good \line \up0 \expndtw-10\c
harscalex95 hygiene and infection control because a new pair is used for each co
n-\line \up0 \expndtw-9\charscalex91 sumer. For consumers whose neck region is s
o spastic that the head rests \line \up0 \expndtw-10\charscalex93 permanently on
one shoulder or so hypotonic that the head hardly main-\line \up0 \expndtw-9\ch
arscalex92 tains a supine position, insert earphones best serve our evaluation n
eeds. \line \up0 \expndtw-10\charscalex95 If the head of the consumer is too sma
ll, as seen in microcephalus and \line \up0 \expndtw-9\charscalex93 sometimes in
Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s syndrome
, or too big, as in hydrocephalus, or if the \line \up0 \expndtw-10\charscalex90
pinnae are malformed, the use of earphones may not be possible because \line \u
p0 \expndtw-9\charscalex94 they may not t properly. If the earphones are too larg
e, they may cause \line \up0 \expndtw-10\charscalex95 an overlapping of the ears
, which allows some of the sound stimulus to \line \up0 \expndtw-9\charscalex97
leak out. In hydrocephalic consumers with large heads, it is always di\u8260?-\l
ine \up0 \expndtw-9\charscalex96 cult to adjust the headphones to su\u8260?cient
ly cover the ears, and this may \line \up0 \expndtw-9\charscalex91 also cause so
und leakage from the standard earphone. If insert earphones \line \up0 \expndtw9\charscalex95 are used e\u8260?ciently, they can lessen problems with collapsib
le ear canals \line \up0 \expndtw-10\charscalex93 and problems with sound leakag
e and minimize the increased interaural \line \up0 \expndtw-9\charscalex91 atten

uation seen with standard earphones (W|lber, 2002). The presence of

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514500145145001451450014514500145145007fffd9}}}}}\pard\sb0\sl-240{\bkmkstart Pg5
6}{\bkmkend Pg56}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253\
slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2857 \up0 \expndtw-10\charsca
lex97 \ul0\nosupersub\cf2\f3\fs22 36\tab \up0 \expndtw-8\charscalex97 \ul0\nosup
ersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\par
d\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\s
b0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\
slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\pa
r\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1
551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl
-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmul
t0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\par
d\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\s
b0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\
slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\pa
r\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1
551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl
-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmul
t0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\par
d\li1551\sb165\sl-207\slmult0\fi0\tx2493 \up0 \expndtw-8\charscalex96 Figure 2.1
\tab \up0 \expndtw-7\charscalex97 A clinician prepares a consumer for an evaluat
ion using insert earphones.\par\pard\li1551\sb13\sl-207\slmult0\fi0 \up0 \expndt
w-8\charscalex96 (Photo printed with permission.)\par\pard\sect\sectd\fs24\paper
w8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg57}{\bkmkend Pg57}\par\pard\li291
3\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb201\sl
-241\slmult0\fi0\tx7302 \up0 \expndtw-8\charscalex92 \ul0\nosupersub\cf5\f6\fs18
Cerebral Palsy/Developmental Disabilities\tab \up0 \expndtw-10\charscalex92 \ul
0\nosupersub\cf2\f3\fs22 37\par\pard\qj \li1286\sb0\sl-253\slmult0 \par\pard\qj\
li1286\ri960\sb55\sl-253\slmult0 \up0 \expndtw-10\charscalex93 collapsible ear c
anals is suspected if immittance measurements ndings \up0 \expndtw-9\charscalex94
are normal, but a high-frequency conductive hearing loss is present \up
0 \expndtw-10\charscalex95 (Kile, 1996). In general, we can state ve good reasons
why the use of \up0 \expndtw-10\charscalex90 insert earphones is recommended: \
par\pard\ql \li1764\sb147\sl-253\slmult0 \up0 \expndtw-10\charscalex95 1. They a
re comfortable and lightweight. \par\pard\qj \li1764\ri962\sb2\sl-260\slmult0\tx
2019 \up0 \expndtw-10\charscalex91 2. There is no need for masking because of th
e increased interaural \line\tab \up0 \expndtw-10\charscalex92 attenuation, whic
h is minimized. \par\pard\ql \li1764\sb6\sl-253\slmult0 \up0 \expndtw-10\charsca
lex92 3. The chance for ear canal collapse is minimal. \par\pard\ql \li1764\sb7\
sl-253\slmult0 \up0 \expndtw-10\charscalex91 4. They are disposable and hygienic
. \par\pard\qj \li1764\ri960\sb2\sl-260\slmult0\tx2010 \up0 \expndtw-10\charscal
ex93 5. Sound is delivered closer to the tympanic membrane compared \line\tab \
up0 \expndtw-10\charscalex94 with conventional earphones. \par\pard\qj \li1286\r
i959\sb120\sl-260\slmult0\fi478 \up0 \expndtw-8\charscalex100 W|th consumers who
have high levels of cognitive function, it is \line \up0 \expndtw-9\charscalex9
5 still important to state and restate test instructions before and during the \
line \up0 \expndtw-9\charscalex95 evaluation. Restating the instructions periodi
cally helps to keep the con-\line \up0 \expndtw-9\charscalex92 sumer focused and
gives the clinician the assurance that the consumer is \line \up0 \expndtw-10\c
harscalex93 engaged with the ongoing evaluation. For consumers who are nonverbal
\line \up0 \expndtw-10\charscalex93 or who have severe neurologic problems or c
ognitive decits or who are \line \up0 \expndtw-10\charscalex90 uncooperative, oth
er test methods and response modes should be used. \par\pard\ql \li2423\sb0\sl-2
07\slmult0 \par\pard\ql\li2423\sb0\sl-207\slmult0 \par\pard\ql\li2423\sb150\sl-2
07\slmult0 \up0 \expndtw0\charscalex104 \ul0\nosupersub\cf7\f8\fs24 B\ul0\nosupe
rsub\cf31\f32\fs17 EHAVIORAL\ul0\nosupersub\cf7\f8\fs24 O\ul0\nosupersub\cf31\f
32\fs17 BSERVATION\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UD
IOMETRY \par\pard\qj \li1286\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb13\s
l-258\slmult0\fi478 \up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Be

havioral observation audiometry (BOA) is a test method that \line \up0 \expndtw
-10\charscalex92 assesses the general behavioral changes of a consumer to sounds
. BOA \line \up0 \expndtw-9\charscalex94 has been used as an audiologic procedur
e mostly for infants with mental \line \up0 \expndtw-10\charscalex94 ages younge
r than 6 months. However, this technique can also be used \line \up0 \expndtw-10
\charscalex94 for nonverbal consumers with severe cognitive and neuromotor decits
. \line \up0 \expndtw-10\charscalex93 BOA can serve as a screening tool (Thompso
n & Weber, 1974) or as an \line \up0 \expndtw-9\charscalex95 evaluation tool (Ta
lbott, 1987). In BOA the clinician is usually the exam-\line \up0 \expndtw-9\cha
rscalex95 iner and other support sta, who are trained to act as judges for observ
-\line \up0 \expndtw-10\charscalex94 ing any behavioral changes or responses whe
never auditory stimuli are \line \up0 \expndtw-9\charscalex97 presented, are als
o involved. The clinician alerts the judges in the test \line \up0 \expndtw-9\ch
arscalex100 room before the presentation of auditory signals. The judges and the
\line \up0 \expndtw-10\charscalex96 clinician will then determine whether a res
ponse was indeed an actual \line \up0 \expndtw-9\charscalex92 response or not a
response. Test stimuli that are presented through insert \line \up0 \expndtw-10\
charscalex95 earphones or loudspeakers may be warble tone, narrow band noise, or
\line \up0 \expndtw-10\charscalex96 a live voice. Because pure tones and warble
tone are much more di\u8260?cult
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
58}{\bkmkend Pg58}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2856 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 38\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-258\slmult0 \par\pard\qj\li1551\ri694\sb73\sl-258\slmult0 \
up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\f3\fs22 to attend to, it is pre
ferable to use narrow band noise signals with this \line \up0 \expndtw-9\charsca
lex100 population. The use of narrow band noise signals can yield valid and \lin
e \up0 \expndtw-9\charscalex95 reliable hearing thresholds even better than use
of pure tones (Sanders \line \up0 \expndtw-9\charscalex100 & Josey, 1970). In re
al life people do not listen to pure tones, and it is \line \up0 \expndtw-10\cha
rscalex94 much easier for them to attend to narrow band noise signals. The draw\line \up0 \expndtw-5\charscalex100 back with the use of narrow band noise signa
ls is that they tend to \line \up0 \expndtw-9\charscalex93 underestimate hearin
g thresholds in the higher frequencies; however, \line \up0 \expndtw-9\char
scalex98 they still retain the value of frequency specicity like pure t
ones \line \up0 \expndtw-10\charscalex94 (Sanders & Josey, 1970). Consumers give
a wide variety of responses. \line \up0 \expndtw-9\charscalex91 Because many co
nsumers\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 respons
es are prone to habituation, it is impor-\line \up0 \expndtw-3\charscalex100 tan
t for both the judges and the clinician to be vigilant to the initial \line \up0
\expndtw-10\charscalex92 response to signals that were presented. Once a consum
er\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s response to
\line \up0 \expndtw-9\charscalex94 an initial signal has become habituated, a n
ew and novel stimulus will be \line \up0 \expndtw-9\charscalex95 needed to elici
t a new response. If the initial stimulus were to be warble \line \up0 \expndtw9\charscalex95 tone, it might be useful to alternate with narrow band noise or l
ive voice. \line \up0 \expndtw-9\charscalex93 However, to maintain consistency w

ith one stimulus, the alternate signals \line \up0 \expndtw-7\charscalex100 mere
ly serve as distractions or interludes to make the initial stimulus \line \up0 \
expndtw-8\charscalex100 novel and dierent all over again. Whenever consumers habi
tuate to \line \up0 \expndtw-8\charscalex100 signals, they lose interest, and it
is di\u8260?cult to evoke responses even at \line \up0 \expndtw-6\charscalex100
signicantly higher intensity levels of presentation. It is important to \line \u
p0 \expndtw-10\charscalex96 note consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\u
l0\nosupersub\cf2\f3\fs22 s chronologic and mental age of development and also \
line \up0 \expndtw-9\charscalex94 the individual\ul0\nosupersub\cf11\f12\fs22 \u
8217?\ul0\nosupersub\cf2\f3\fs22 s medical disposition. A knowledge of results o
f a previous \line \up0 \expndtw-10\charscalex93 audiogram may bias the outcome
of the current evaluation. Thus even if \line \up0 \expndtw-9\charscalex94 the p
revious evaluation was done by the same clinician, it is advisable to \line \up0
\expndtw-10\charscalex96 use it only for the purpose of comparison after the ne
w evaluation has \line \up0 \expndtw-10\charscalex93 been concluded. As previous
ly noted, consumers display a wide array of \line \up0 \expndtw-9\charscalex93 b
ehaviors in response to auditory stimuli. These can be grouped into two \line \u
p0 \expndtw-9\charscalex92 categories: (1) attentive orienting and (2) reexive be
haviors described by \line \up0 \expndtw-9\charscalex95 Diefendor (2002) as di
splayed in Table 2.2. According to Diefendorf \line \up0 \expndtw-8\charscal
ex100 (2002), consumers with higher levels of cortical functioning who can \line
\up0 \expndtw-9\charscalex96 attach meaning to sound are more likely to exhibit
attentive or orienting \line \up0 \expndtw-8\charscalex100 types of behaviors t
o auditory stimuli than are those who present the \line \up0 \expndtw-5\charscal
ex100 reexive type of behavior but who cannot attach much meaning to \line \up0 \
expndtw-10\charscalex90 sound. \par\pard\qj \li1551\ri695\sb1\sl-260\slmult0\fi4
78 \up0 \expndtw-7\charscalex100 A major limitation to the use of BOA that is of
ten cited is that it \up0 \expndtw-9\charscalex91 measures a consumer\ul0\nosupe
rsub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s responsiveness to sound
rather than sensitivity to \up0 \expndtw-9\charscalex95 sound. Despite this limi
tation, BOA can be used as one portion of a test \up0 \expndtw-10\charscalex92 b
attery approach for evaluation.
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz87\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
59}{\bkmkend Pg59}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7294 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 39\par\pard\li1286\sb0
\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\sl
mult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\
pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li128
6\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-2
07\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0
\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb126\sl-207\slmult0\fi2770
\up0 \expndtw-6\charscalex100 \ul0\nosupersub\cf5\f6\fs18 Table 2.2\par\pard\li1
286\sb72\sl-207\slmult0\fi843 \up0 \expndtw-6\charscalex100 Behavioral Responses
of Children with Severe Disabilities\par\pard\li1286\sb131\sl-207\slmult0\fi0\t
x5342 \up0 \expndtw-6\charscalex100 Behavior Type\tab \up0 \expndtw-6\charscalex
100 Responses\par\pard\li1286\sb79\sl-207\slmult0\fi0\tx3917 \up0 \expndtw-6\cha
rscalex100 Attentive/orienting\tab \up0 \expndtw-6\charscalex100 Smiling\par\par

d\qj \li3918\ri3901\sb0\sl-220\slmult0 \up0 \expndtw-8\charscalex100 Laughing \l

ine \up0 \expndtw-8\charscalex100 Crying \par\pard\qj \li3918\ri3808\sb0\sl-220\
slmult0 \up0 \expndtw-6\charscalex100 Grimacing \line \up0 \expndtw-8\charscalex
91 Searching \line \up0 \expndtw-8\charscalex92 Pointing \par\pard\ql \li3918\sb
0\sl-207\slmult0 \up0 \expndtw-8\charscalex93 Slightly repeatable movement of bo
dy parts \par\pard\li1286\sb21\sl-207\slmult0\fi0\tx3917 \up0 \expndtw-8\charsca
lex95 Reflexive\tab \up0 \expndtw-8\charscalex95 Body startle\par\pard\ql \li391
8\sb5\sl-207\slmult0 \up0 \expndtw-8\charscalex94 Initiation or cessation of suc
king \par\pard\ql \li3918\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex91 Incre
ased or decreased sucking, eye blink, or flutter \par\pard\qj \li1286\ri1009\sb1
79\sl-200\slmult0 \up0 \expndtw-6\charscalex98 \ul0\nosupersub\cf3\f4\fs16 Adapt
ed from Diefendorf, A. O. (2002). Detection and assessment of hearing loss in in
fants and \line \up0 \expndtw-6\charscalex93 children. In J. Katz (Ed.). Handboo
k of clinical audiology (5th ed.). New York: Lippincott W|lliams and \line \up0
\expndtw-7\charscalex93 W|lkins.
{\shp {\*\shpinst\shpleft1286\shptop4528\shpright7503\shpbottom4549\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz6\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 21}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(6217,0);(6217,21);(0,21)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1286\shptop7169\shpright7503\shpbottom7189\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(6217,0);(6217,20);(0,20)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1286\shptop4828\shpright7503\shpbottom4848\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz10\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz57\shplid3
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s

p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s

p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
60}{\bkmkend Pg60}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2860 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 40\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\ql \li2801\sb0\sl-207\slmult0 \par\pard\ql\li2801\sb186\sl-207\slmult0 \up0 \
expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 V\ul0\nosupersub\cf31\f32\fs1
7 ISUAL\ul0\nosupersub\cf7\f8\fs24 R\ul0\nosupersub\cf31\f32\fs17 EINFORCEMENT\
ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UDIOMETRY \par\pard\q
j \li1551\ri697\sb246\sl-265\slmult0\fi478 \up0 \expndtw-10\charscalex100 \ul0\n
osupersub\cf2\f3\fs22 V|sual reinforcement audiometry (VRA) is a method of obtai
ning \line \up0 \expndtw-9\charscalex94 hearing thresholds that is most app
ropriate with severely physically \line \up0 \expndtw-10\charscalex95 challen
ged consumers (Decker & W|lson, 1977; Talbott, 1987). VRA is \line \up0 \expndt
w-10\charscalex96 an operant conditioning response and can be used to evaluate c
onsu-\line \up0 \expndtw-10\charscalex87 mers aged 1.5 ^2 \up0 \expndtw-10\cha
rscalex92 years and older \up0 \expndtw-10\charscalex93 (Evenhuis, 1996). Du
ring operant \par\pard\qj \li1551\ri694\sb0\sl-264\slmult0 \up0 \expndtw-9\char
scalex93 conditioning, the auditory stimulus presented evokes the consume
r\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s \line \up0 \
expndtw-9\charscalex95 response, which results in a head-turn toward the
direction of the \line \up0 \expndtw-8\charscalex100 sound (localization).
A head-turn toward the direction of the sound \line \up0 \expndtw-10\charscal
ex96 becomes the operant behavior that is rewarded by giving positive rein-\line
\up0 \expndtw-8\charscalex100 forcement. If the positive reinforcement is of in
terest and value to the \line \up0 \expndtw-9\charscalex98 consumer, his or her
attention will be sustained and the head-turn will \line \up0 \expndtw-9\charsca
lex100 continue whenever the auditory stimulus is presented until the proce-\lin
e \up0 \expndtw-8\charscalex100 dure is completed. To obtain valid and rel
iable results with VRA, \line \up0 \expndtw-9\charscalex96 training sessions
are necessary. The training trials or conditioning \line \up0 \expndtw-7\
charscalex100 involves pairing the auditory stimulus with a reinforcer. For inst
ance, \line \up0 \expndtw-4\charscalex100 presentation of sound is paired with i
llumination of a clown or doll \line \up0 \expndtw-9\charscalex98 above a loud
speaker. Once the clinician is satised that desired \line \up0 \expndtw-10
\charscalex95 responses have been achieved consistently upon presentation of aud
i-\line \up0 \expndtw-9\charscalex98 tory stimuli after a few trials, the actual
evaluation can then begin. For \line \up0 \expndtw-9\charscalex100 very young c
onsumers, it is advisable to ask the parent or signicant \line \up0 \expndtw-7\ch
arscalex100 other whether the individual is frightened by loud sounds or moving
\line \up0 \expndtw-8\charscalex100 toys. This information is important so that
the consumer is not upset \line \up0 \expndtw-9\charscalex94 inadvertently. Som
e reinforcers that provoke laughter, curiosity, and \line \up0 \expndtw-10
\charscalex96 interest in one consumer may evoke the opposite reaction of an
ger, \line \up0 \expndtw-8\charscalex100 crying, and lack of interest in another
. Thus the conditioning periods \line \up0 \expndtw-9\charscalex96 should also s
erve to screen reinforcers that are likely to be problematic \line \up0 \expndtw
-9\charscalex97 during the actual procedure. In VRA, visual reinforcers a
re mostly \line \up0 \expndtw-9\charscalex98 three-dimensional objects usual
ly brightly colored clowns or toys \line \up0 \expndtw-10\charscalex95 that
can move when activated. Young (1994) suggests caution in using \line \up0 \exp
ndtw-9\charscalex97 VRA with consumers who have a history of seizures th
at can be \line \up0 \expndtw-3\charscalex100 triggered by bright or ickering
visual stimuli. VRA can be di\u8260?cult \line \up0 \expndtw-9\charscalex100 or
almost impossible as an evaluation technique for some consumers \line \up0 \expn
dtw-10\charscalex95 with CP whose head and neck region is so spastic or so hypot
onic that \line \up0 \expndtw-8\charscalex100 head control is very di\u8260?cult
to maintain (Siegenthaler, 1987). The use \line \up0 \expndtw-10\charscalex96

of insert earphones with this group of consumers and in those who are
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz94\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
61}{\bkmkend Pg61}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7298 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 41\par\pard\qj \li1286
\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw10\charscalex95 microcephalic or hydrocephalic can be very convenient and succes
sful \line \up0 \expndtw-9\charscalex93 (W|den & O\ul0\nosupersub\cf11\f12\fs2
2 \u8217?\ul0\nosupersub\cf2\f3\fs22 Grady, 2002). Because consumers can qu
ickly habituate \line \up0 \expndtw-8\charscalex100 their responses, it is w
ise to work fast, especially through initial \line \up0 \expndtw-9\charsca
lex98 conditioning trial periods. The clinician may talk to, smile at,
and \line \up0 \expndtw-6\charscalex100 interact with the consumer. This cr
eates better bonding of the \line \up0 \expndtw-8\charscalex100 consumer wit
h the clinician and removes or reduces the expectation \line \up0 \expndtw-7\cha
rscalex100 of an impending dangerous event that is about to happen in the test \
line \up0 \expndtw-9\charscalex96 environment. The examination should be ma
de as free of tension \line \up0 \expndtw-9\charscalex96 as possible for
the consumer. VRA can be an eective evaluation \line \up0 \expndtw-6\charsc
alex100 tool for use with consumers who have severe to profound cognitive \line
\up0 \expndtw-10\charscalex94 decits (Decker & W|lson, 1977; Talbott, 1987; Th
ompson, W|lson, & \line \up0 \expndtw-10\charscalex88 More, 1979). \par\pard\ql
\li3258\sb0\sl-218\slmult0 \par\pard\ql\li3258\sb0\sl-218\slmult0 \par\pard\ql\
li3258\sb120\sl-218\slmult0 \up0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\
fs24 A\ul0\nosupersub\cf31\f32\fs17 IR\ul0\nosupersub\cf7\f8\fs24 P\ul0\nosuper
sub\cf31\f32\fs17 UFF\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17
UDIOMETRY \par\pard\qj \li1286\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb1
1\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex97 \ul0\nosupersub\cf2\f3\fs22
Air pu audiometry is a new procedure (Lancioni & Coninx, \line \up0 \ex
pndtw-10\charscalex95 1995) that has been used with consumers who have severe di
sabilities \line \up0 \expndtw-7\charscalex100 and multiple handicaps. Air pu aud
iometry is a classic conditioning \line \up0 \expndtw-6\charscalex100 procedure
in which an air pu (unconditioned stimulus) is paired to \line \up0 \expndtw-9\c
harscalex96 an auditory stimulus (conditioned stimulus). The air pu can be direct
ed \line \up0 \expndtw-9\charscalex91 to the consumer\ul0\nosupersub\cf11\f12\f
s22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s face, eyes, or neck and evokes defe
nsive responses \line \up0 \expndtw-9\charscalex96 such as eye blinks or head tu
rns. This procedure is not yet widely used \line \up0 \expndtw-7\charscalex100 c
linically, especially in this country. The air pu is generated from an \line \up0
\expndtw-7\charscalex100 air cylinder \up0 \expndtw-8\charscalex100 lled with
compressed air, and a sound generating \line \up0 \expndtw-7\charscalex100
system provides the auditory stimulus with which the air pu is \line \
up0 \expndtw-8\charscalex100 paired. Lancioni and Coninx (1995) reported that a
ir pu audiometry \line \up0 \expndtw-9\charscalex97 is as eective as VRA in t
he assessment of multiply handicapped \line \up0 \expndtw-10\charscalex87 co
nsumers. \par\pard\ql \li2411\sb0\sl-207\slmult0 \par\pard\ql\li2411\sb0\sl-207\
slmult0 \par\pard\ql\li2411\sb151\sl-207\slmult0 \up0 \expndtw0\charscalex105 \u
l0\nosupersub\cf7\f8\fs24 O\ul0\nosupersub\cf31\f32\fs17 THER\ul0\nosupersub\cf7

\f8\fs24 B\ul0\nosupersub\cf31\f32\fs17 EHAVIORAL\ul0\nosupersub\cf7\f8\fs24 E

\ul0\nosupersub\cf31\f32\fs17 VALUATION\ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupe
rsub\cf31\f32\fs17 OOLS \par\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1
286\ri959\sb10\sl-260\slmult0\fi478 \up0 \expndtw-9\charscalex100 \ul0\nosupersu
b\cf2\f3\fs22 Conditioned play audiometry (CPA) and tangible reinforcement \up0
\expndtw-10\charscalex95 operant conditioning audiometry (TROCA) are other beha
vioral evalua\up0 \expndtw-9\charscalex96 tion tools based on operant condi
tioning techniques. In these two \up0 \expndtw-10\charscalex90 evaluation pr
ocedures the consumer must make physical motor responses \up0 \expndtw-10\charsc
alex91 to auditory stimuli.
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz106\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
62}{\bkmkend Pg62}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2855 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 42\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\ql \li1793\sb0\sl-253\slmult0 \par\pard\ql\li1793\sb82\sl-253\slmult0 \up0 \e
xpndtw-1\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Tangible Reinforcement Operan
t Conditioning Audiometry \par\pard\qj \li1551\ri697\sb122\sl-260\slmult0\fi478
\up0 \expndtw-4\charscalex100 In TROCA the consumer is required to push a button
, which \line \up0 \expndtw-10\charscalex90 dispenses a tangible reinforcer \
up0 \expndtw-10\charscalex91 (usually something edible such as an \par\pard
\qj \li1551\ri695\sb0\sl-265\slmult0 \up0 \expndtw-10\charscalex95 M&M or a toke
n). TROCA, unlike other behavioral evaluation methods, \line \up0 \expndtw-10\ch
arscalex91 was developed using developmentally disabled consumers in the process
\line \up0 \expndtw-9\charscalex94 and has been used by many clinicians in eval
uating hearing sensitivities \line \up0 \expndtw-10\charscalex97 of consumers (B
ess & Humes, 1990). A major drawback with TROCA \line \up0 \expndtw-9\charscalex
95 is in the choice of appropriate reinforcers, especially for consumers with \l
ine \up0 \expndtw-9\charscalex97 severe to profound disabilities (Friedrich, 19
85). Even a simple edible \line \up0 \expndtw-9\charscalex95 reinforcer such a
s an M&M may be dangerous if, for example, the \line \up0 \expndtw-10\cha
rscalex97 consumer is allergic to peanuts or other foods. TROCA does not work \l
ine \up0 \expndtw-10\charscalex97 for many consumers with CP because of their in
voluntary movements \line \up0 \expndtw-10\charscalex95 and the presence of prim
itive reexes. These physical challenges tend \line \up0 \expndtw-9\charscalex100
to compound the consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2
\f3\fs22 s inability to make appropriate responses \line \up0 \expndtw-10\charsc
alex92 whenever auditory stimuli are presented. \par\pard\ql \li3220\sb0\sl-253\
slmult0 \par\pard\ql\li3220\sb108\sl-253\slmult0 \up0 \expndtw-1\charscalex100 C
onditioned Play Audiometry \par\pard\qj \li1551\ri694\sb138\sl-264\slmult0\fi478
\up0 \expndtw-7\charscalex100 During CPA, the consumer is conditioned to drop b
locks in the \up0 \expndtw-6\charscalex100 bucket or stack up donut rings in res
ponse to an auditory stimulus. \up0 \expndtw-10\charscalex92 Evenhuis (1996) sug
gested the use of CPA with consumers in the devel\up0 \expndtw-10\charscalex92 o
pmental age range of between 2.5 to 3 years and older. However, apart \up0 \expn
dtw-9\charscalex93 from the consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\no
supersub\cf2\f3\fs22 s level of cognition, the presence or absence of physi\up0
\expndtw-9\charscalex94 cal challenges should constitute a major consideration.
The goal of pure \up0 \expndtw-6\charscalex100 tune audiometry is to obtain the

degree, conguration, and type of \up0 \expndtw-9\charscalex100 hearing loss. In

our practice we consider 30 dB hearing level (HL) as \up0 \expndtw-9\charscalex9
7 acceptable for\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf
2\f3\fs22 normal\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\
f3\fs22 hearing, giving allowances for the challenges \up0 \expndtw-10\charscal
ex93 posed by the individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub
\cf2\f3\fs22 s disability. \par\pard\ql \li3624\sb0\sl-207\slmult0 \par\pard\ql\
li3624\sb0\sl-207\slmult0 \par\pard\ql\li3624\sb150\sl-207\slmult0 \up0 \expndtw
0\charscalex102 \ul0\nosupersub\cf7\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 PEECH
\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UDIOMETRY \par\pard\
qj \li1551\sb0\sl-265\slmult0 \par\pard\qj\li1551\ri697\sb1\sl-265\slmult0\fi478
\up0 \expndtw-10\charscalex89 \ul0\nosupersub\cf2\f3\fs22 Pure tones are used t
o assess the degree and type of hearing impair-\line \up0 \expndtw-10\charscalex
94 ment. However, people do not communicate in pure tones. W|th speech \line \up
0 \expndtw-10\charscalex96 audiometry we are able to assess a consumer\ul0\nosup
ersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ability to perceive and
\line \up0 \expndtw-9\charscalex91 recognize various speech sounds. Therefor
e the main goal of speech \line \up0 \expndtw-10\charscalex91 audiometry is
to provide information about the consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\
ul0\nosupersub\cf2\f3\fs22 s ability to
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz90\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
63}{\bkmkend Pg63}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7294 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 43\par\pard\qj \li1286
\sb0\sl-257\slmult0 \par\pard\qj\li1286\ri959\sb47\sl-257\slmult0 \up0 \expndtw10\charscalex94 perceive speech. Because many consumers generally respond faster
to \line \up0 \expndtw-9\charscalex93 more familiar speech sounds than to sound
s that are not familiar, speech \line \up0 \expndtw-9\charscalex91 materials are
generally composed of a wide range of frequencies and tend \line \up0 \expndtw9\charscalex94 to elicit quicker responses than pure tones (Ray, 2002; Rittmanic
, 1971). \line \up0 \expndtw-10\charscalex91 Sometimes speech audiometry becomes
the main behavioral clinical eval-\line \up0 \expndtw-10\charscalex96 uation to
ol available when pure tone audiometry cannot be performed, \line \up0 \expndtw10\charscalex96 but speech audiometry cannot provide denitive information about t
he \line \up0 \expndtw-10\charscalex96 type, degree, and conguration of hearing i
mpairment. Mandell (2002) \line \up0 \expndtw-10\charscalex91 described four res
ponse tasks in evaluating speech perception ability: \par\pard\qj \li1764\ri961\
sb141\sl-260\slmult0\tx2010 \up0 \expndtw-10\charscalex96 1. Detection the ab
ility to determine whether a speech stimulus \line\tab \up0 \expndtw-10\charscal
ex87 is present. \par\pard\qj \li1764\ri960\sb0\sl-260\slmult0\tx2019 \up0 \expn
dtw-9\charscalex100 2. Discrimination the ability to distinguish between
whether \line\tab \up0 \expndtw-10\charscalex96 two stimuli are the same or dier
ent. \par\pard\qj \li1764\ri963\sb0\sl-260\slmult0\tx2008 \up0 \expndtw-9\charsc
alex96 3. Identication the ability to recognize a stimulus and identify it \li
ne\tab \up0 \expndtw-10\charscalex96 by repeating it or pointing to a pictorial
representation. \par\pard\qj \li1764\ri960\sb0\sl-260\slmult0\tx2019 \up0 \expnd
tw-10\charscalex93 4. Comprehension the ability to decode or understand the m
ean-\line\tab \up0 \expndtw-10\charscalex94 ing of the speech stimulus. \par\par

d\qj \li1286\ri959\sb120\sl-260\slmult0 \up0 \expndtw-10\charscalex95 Mandell (

2002) suggested the use of various speech stimuli, including \line \up0 \expndtw
-9\charscalex91 a range of phonemes syllables, words, phrases, sentences, and co
nnected \line \up0 \expndtw-9\charscalex89 discourse, to assess each response ta
sk. Assessing these response tasks is \line \up0 \expndtw-9\charscalex100 more d
i\u8260?cult in severely physically challenged consumers, particularly \line \up
0 \expndtw-9\charscalex97 those who are nonverbal and so are unable to repeat, p
oint to, or write \line \up0 \expndtw-10\charscalex97 words that are presented
by the clinician during speech audiometry. \line \up0 \expndtw-10\charscalex94
For consumers with CP and other disabilities who have normal or near-\line \up0
\expndtw-9\charscalex91 normal cognitive abilities and whose physical challenge
s can be described \line \up0 \expndtw-10\charscalex96 as mild, unmodied speech a
udiometry can be performed. That is, the \line \up0 \expndtw-10\charscalex96 con
sumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s speech r
ecognition threshold (SRT) and word recognition \line \up0 \expndtw-9\charscale
x94 (WR) ability can be assessed just like those of the general population by \l
ine \up0 \expndtw-7\charscalex100 using and following the standard and usual pro
tocols. However, it is \line \up0 \expndtw-7\charscalex100 suggested that words
which are more familiar and which can evoke \line \up0 \expndtw-10\charscalex89
some excitement be used. \par\pard\ql \li2932\sb0\sl-253\slmult0 \par\pard\ql\li
2932\sb113\sl-253\slmult0 \up0 \expndtw-5\charscalex100 Speech Recognition Thres
hold \par\pard\qj \li1286\ri959\sb142\sl-260\slmult0\fi478 \up0 \expndtw-10\char
scalex90 We suggest the use of words such as ice cream, cupcake, hot
\line \up0 \expndtw-9\charscalex97 dog, baseball, football, playground, wheelcha
ir, airplane, railroad, rain-\line \up0 \expndtw-10\charscalex97 coat, and tooth
brush, which are familiar to most consumers. Speech
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz83\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
64}{\bkmkend Pg64}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2860 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 44\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-263\slmult0 \par\pard\qj\li1551\ri694\sb64\sl-263\slmult0 \
up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 audiometry can provide
information about the degree of hearing loss \line \up0 \expndtw-5\charscalex100
and how the consumer functions auditorily in the low, mid, or high \line \up0 \
expndtw-10\charscalex95 frequencies. In severely physically challenged consumers
, the conven-\line \up0 \expndtw-9\charscalex100 tional test and response modes
must be modied to make the proce-\line \up0 \expndtw-10\charscalex95 dure more eec
tive and accurate. Byers and Bristow (1990) suggested \line \up0 \expndtw-10\ch
arscalex95 the eyegaze response mode for use with these consumers. In the eye-\l
ine \up0 \expndtw-10\charscalex93 gaze response, nonverbal consumers are to turn
their heads toward and \line \up0 \expndtw-9\charscalex95 gaze with their ey
es or point to the pictorial representation of the \line \up0 \expndtw-9
\charscalex92 words presented. However, this response depends on the deg
ree of \line \up0 \expndtw-4\charscalex100 mobility and voluntary control of th
e head and neck region. In our \line \up0 \expndtw-9\charscalex100 practice we h
ave modied the use of two-dimensional pictorial repre-\line \up0 \expndtw-9\chars
calex95 sentation and replaced it instead with three-dimensional models
of \line \up0 \expndtw-9\charscalex93 words presented. The three-dimensional

models of actual objects, in \line \up0 \expndtw-10\charscalex97 our judgmen

t, are more appealing and exciting and make more sense \line \up0 \expndtw-9\cha
rscalex94 to a lot of consumers than speech items, especially for thos
e with \line \up0 \expndtw-9\charscalex100 lower cognitive abilities. Speech a
udiometry items can be handmade \line \up0 \expndtw-9\charscalex95 in clinics wi
th actual three-dimensional objects such as an apple, an ice \line \up0 \expndtw
-10\charscalex97 cream cone, a hot dog, or an airplane, which are then placed on
clear \line \up0 \expndtw-10\charscalex96 acrylic boards using Velcro. In some
cases, we have used\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\
cf2\f3\fs22 word com-\line \up0 \expndtw-9\charscalex100 mand\ul0\nosupersub\cf1
1\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 phrases, when reliable
responses could not otherwise be \line \up0 \expndtw-9\charscalex89 obtaine
d, but phrases such as\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nos
upersub\cf2\f3\fs22 head up,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \u821
6?\u8216?\ul0\nosupersub\cf2\f3\fs22 hand down,\ul0\nosupersub\cf11\f12\fs22 \u
8217?\u8217? \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 close eyes,\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\u8217? \line \up0 \expndtw-9\charscalex91 \u8216?\u821
6?\ul0\nosupersub\cf2\f3\fs22 open eyes,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8
217?\ul0\nosupersub\cf2\f3\fs22 and\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216
?\ul0\nosupersub\cf2\f3\fs22 stand up,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u821
7?\ul0\nosupersub\cf2\f3\fs22 may require some degree of comprehension \line \u
p0 \expndtw-10\charscalex91 for the consumer to perform these tasks. \par\pard\q
l \li3304\sb0\sl-253\slmult0 \par\pard\ql\li3304\sb233\sl-253\slmult0 \up0 \expn
dtw-9\charscalex100 Speech Awareness Threshold \par\pard\ql \li2030\sb147\sl-253
\slmult0\tx5304 \up0 \expndtw-10\charscalex90 The speech awareness thresho
ld \tab \up0 \expndtw-10\charscalex95 (SAT) becomes the only \par\pard\qj
\li1551\ri695\sb0\sl-266\slmult0 \up0 \expndtw-9\charscalex97 alternative if c
onsumers are unable to participate in SRT or word \line \up0 \expndtw-9\c
harscalex93 command procedures because of limited cognitive abilities or
severe \line \up0 \expndtw-5\charscalex100 neurologic defects. Although the
goal of SRT is to determine \line \up0 \expndtw-10\charscalex94 the lowest
level that can identify speech stimuli correctly, \up0 \expndtw-7\charsc
alex100 50% of \par\pard\qj \li1551\ri697\sb0\sl-260\slmult0 \up0 \expndtw-6\ch
arscalex100 the time SAT merely determines the lowest level at which a
n \line \up0 \expndtw-10\charscalex96 individual can detect the presence of
speech \up0 \expndtw-6\charscalex100 50% of the time. \par\pard\qj \li1551\
ri697\sb0\sl-260\slmult0 \up0 \expndtw-9\charscalex100 SAT can be conducted
using test items that provide frequency-\line \up0 \expndtw-9\charscalex100
specic information for low-, mid-, and high-frequency specic \par\pard\li1
551\sb24\sl-253\slmult0\fi0\tx3473\tx3857\tx4223\tx4637\tx5541\tx5852 \up0 \expn
dtw-10\charscalex93 information such as\tab \up0 \expndtw-10\charscalex93 /a/,
\tab \up0 \expndtw-10\charscalex93 /i/,\tab \up0 \expndtw-10\charscalex93 /u/,\t
ab \up0 \expndtw-10\charscalex93 /sh/, and\tab \up0 \expndtw-10\charscalex93 /s
/\tab \up0 \expndtw-10\charscalex93 (Ling, 1978). Mandell\par\pard\ql \li1551\
sb5\sl-253\slmult0 \up0 \expndtw-10\charscalex95 (2002) suggested the use of /b
a/ and /bu/ for assessing low-frequency
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz83\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
65}{\bkmkend Pg65}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7292 \up0 \expndtw-8\charsca

lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab

\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 45\par\pard\qj \li1286
\sb0\sl-240\slmult0 \par\pard\qj\li1286\ri961\sb78\sl-240\slmult0 \up0 \expndtw9\charscalex93 components, /sh/ for mid to high frequencies, and /s/ fo
r assessing \up0 \expndtw-10\charscalex93 mainly high frequencies. \par\pard\ql
\li3143\sb0\sl-253\slmult0 \par\pard\ql\li3143\sb137\sl-253\slmult0 \up0 \expnd
tw0\charscalex102 Word Recognition Ability \par\pard\qj \li1286\ri959\sb143\sl-2
58\slmult0\fi478 \up0 \expndtw-10\charscalex94 Generally, regular word recogniti
on test items used for the general \line \up0 \expndtw-7\charscalex100 populatio
n can also be used for consumers who have mild or near-\line \up0 \expndtw-10\c
harscalex95 normal cognition. For more developmentally challenged consumer
s \line \up0 \expndtw-8\charscalex100 with CP, speech items used with children c
an be modied and used \line \up0 \expndtw-9\charscalex93 (Evenhuis, 1996). For in
stance, the use of modied versions of the Word \line \up0 \expndtw-9\charscalex10
0 Intelligibility by Picture Identication (WIPI) word list (Ross & Lerman, \line
\up0 \expndtw-9\charscalex91 1970) can be used.W|th the use of Velcro, models of
words presented can \line \up0 \expndtw-9\charscalex97 be placed on acrylic boa
rds similar to those used for SRT. Usually it is \line \up0 \expndtw-9\charscale
x100 easier for consumers to identify words with three-dimensional models \line
\up0 \expndtw-10\charscalex94 because they look more real than two-dimensional p
ictures or diagrams \line \up0 \expndtw-9\charscalex95 of objects.Words for fami
liar items found in the consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupe
rsub\cf2\f3\fs22 s environment \line \up0 \expndtw-9\charscalex93 such as spoon,
fork, cup, chair, milk, straw, cake, shirt, and pants can be \line \up0 \expndt
w-10\charscalex97 used. In addition, word commands can be useful, especially wit
h non-\line \up0 \expndtw-10\charscalex95 verbal consumers without serious physi
cal limitations who can compre-\line \up0 \expndtw-10\charscalex97 hend and foll
ow simple word command instructions. Word recognition \line \up0 \expndtw-9\char
scalex100 ability can be measured by the use of phrases such as show me your \li
ne \up0 \expndtw-10\charscalex94 head, mouth, eyes, nose, lips, teeth, etc. For
nonverbal consumers who \line \up0 \expndtw-9\charscalex93 are more physically
compromised, the eyegaze technique previously \line \up0 \expndtw-10\chars
calex91 described under the heading Speech Recognition Threshold can be used. \p
ar\pard\ql \li2802\sb0\sl-195\slmult0 \par\pard\ql\li2802\sb0\sl-195\slmult0 \pa
r\pard\ql\li2802\sb185\sl-195\slmult0 \up0 \expndtw0\charscalex101 \ul0\nosupers
ub\cf7\f8\fs24 E\ul0\nosupersub\cf31\f32\fs17 LECTROPHYSIOLOGIC\ul0\nosupersub\c
f7\f8\fs24 M\ul0\nosupersub\cf31\f32\fs17 EASURES \par\pard\qj \li1286\sb0\sl-2
57\slmult0 \par\pard\qj\li1286\ri959\sb17\sl-257\slmult0\fi478 \up0 \expndtw-10\
charscalex93 \ul0\nosupersub\cf2\f3\fs22 Accurate and reliable evaluation ndings
are essential for selecting \line \up0 \expndtw-9\charscalex92 appropriate inter
vention strategies and for achieving desired rehabilitative \line \up0 \expndtw10\charscalex97 outcomes. An inability to respond to presented test stimuli beca
use of \line \up0 \expndtw-9\charscalex94 hypotonia, severe spasticity, severe t
o profound cognitive decits, unco-\line \up0 \expndtw-10\charscalex91 operative b
ehavior, and sometimes unpredictable behaviors of consumers \line \up0 \expndtw9\charscalex94 with CP and autistic features who may constantly grab test equipm
ent or \line \up0 \expndtw-10\charscalex97 move around the test environment duri
ng the evaluation, often makes \line \up0 \expndtw-8\charscalex100 assessment ve
ry challenging and di\u8260?cult to accomplish. Thus physio-\line \up0 \expndtw10\charscalex94 logic measures such as ABR, OAE, and immittance have be
come \line \up0 \expndtw-10\charscalex91 almost routine methods in hearing asses
sment.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s

p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
66}{\bkmkend Pg66}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2859 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 46\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\ql \li3389\sb0\sl-253\slmult0 \par\pard\ql\li3389\sb82\sl-253\slmult0 \up0 \e
xpndtw-4\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Immittance Measurements \par\
pard\qj \li1551\ri695\sb120\sl-262\slmult0\fi478 \up0 \expndtw-9\charscalex100 A
fter otoscopic examination of the ear canals to ensure that the \line \up0 \expn
dtw-10\charscalex94 pathway is free of excessive cerumen accumulation, debris, a
nd foreign \line \up0 \expndtw-10\charscalex92 objects, immittance measurements
are taken. Immittance is an important \line \up0 \expndtw-7\charscalex100 object
ive evaluation tool used to evaluate the integrity of the middle \line \up0 \exp
ndtw-9\charscalex94 ear system of consumers, particularly those with Down
\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s syndrome \li
ne \up0 \expndtw-8\charscalex100 for whom middle ear pathologic conditions
are very prevalent. It \line \up0 \expndtw-9\charscalex94 is often stated th
at testee cooperation or participation during electrophy-\line \up0 \expndtw-10\
charscalex96 siologic measures is not important, unlike with behavioral assessme
nt. \line \up0 \expndtw-10\charscalex97 However, for consumers who have spastic
athetosis and often exhibit \line \up0 \expndtw-10\charscalex95 involuntary move
ments, obtaining physiologic measurements including \line \up0 \expndtw-9\charsc
alex97 immittance can be a challenge. Obtaining and maintaining air-tight
\line \up0 \expndtw-9\charscalex96 seals to accomplish the immittance procedure
can be di\u8260?cult, especially \line \up0 \expndtw-6\charscalex100 if the cons
umer refuses to cooperate by ripping the probe tips from \line \up0 \expndtw-8\c
harscalex100 the ears. This is very common with consumers who have behavioral \l
ine \up0 \expndtw-10\charscalex93 problems. Immittance measurements comprise thr
ee main components: \line \up0 \expndtw-9\charscalex93 tympanometry, static co
mpliance, and acoustic reex measurements. \line \up0 \expndtw-10\charscalex96
Immittance measures the mobility of the tympanic membrane, integrity \line \up0
\expndtw-10\charscalex88 of the ossicles \up0 \expndtw-10\charscalex95 (middl
e ear bones), Eustachian tube function, middle \line \up0 \expndtw-9\charsca
lex92 ear pressure, and the stapedial acoustic reex. When tympanometric \l
ine \up0 \expndtw-9\charscalex94 ndings are normal, the absence of acoustic
reexes may indicate \line \up0 \expndtw-9\charscalex96 loss of stapedial musc
le function or severe sensorineural hearing loss \line \up0 \expndtw-10\charsc
alex96 or dysfunction of the acoustic-facial reex \up0 \expndtw-10\charscale
x96 (Maurizi, Ottaviani, & \par\pard\ql \li1551\sb6\sl-253\slmult0 \up0 \expnd
tw-10\charscalex86 Paludetti, 1995). \par\pard\qj \li1551\ri697\sb0\sl-262\slmul
t0\fi478 \up0 \expndtw-10\charscalex97 Once the consumer can cooperate, tympanom
etric and acoustic \up0 \expndtw-10\charscalex90 reex measurements can be taken.
Results from these measurements are \up0 \expndtw-10\charscalex95 similar compar
ed with those for the general population (Fulton & Lamb, \up0 \expndtw-10\charsc
alex95 1972). However, in the consumer population with Down\ul0\nosupersub\cf11\
f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s syndrome, in \up0 \expndtw-10\char
scalex94 whom conductive hearing loss is very prevalent due to Eustachian tube \
up0 \expndtw-9\charscalex100 dysfunction (MCW Health Link, 2002), tympanometri
c abnormalities \up0 \expndtw-10\charscalex95 range widely from 32 to 68%
(Keiser, Montague, Wold, Maune, & \up0 \expndtw-10\charscalex89 Pattison, 198
1; Mazzoni, Ackley, & Nash, 1994). \par\pard\qj \li1551\ri696\sb0\sl-265\slmult0
\fi478 \up0 \expndtw-8\charscalex100 Stenotic ear canals, commonly found in Down
\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s syndrome, can
\line \up0 \expndtw-10\charscalex96 compromise tympanometric measurements, e
specially when some \line \up0 \expndtw-10\charscalex96 amount of cerumen is p
resent in the ear canals (Kile, 1996). Therefore \line \up0 \expndtw-10\charscal
ex97 external ear canals should be thoroughly inspected before immittance \line

\up0 \expndtw-10\charscalex91 measurements are taken. Acoustic reex measurements

have been used
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
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{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
67}{\bkmkend Pg67}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7298 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 47\par\pard\qj \li1286
\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri960\sb42\sl-260\slmult0 \up0 \expndtw9\charscalex92 to determine hearing thresholds (Green & Margolis, 1983; Hannley,
1984; \up0 \expndtw-10\charscalex92 Jerger, Burney, Mauldin, & Crump, 1974; Nie
meyer & Sesterhenn, 1974) \up0 \expndtw-10\charscalex95 in severely impaired con
sumers. W|th the advent of ABR and OAE, the \up0 \expndtw-10\charscalex92 use of
this procedure appears to be diminishing. \par\pard\ql \li3321\sb0\sl-253\slmul
t0 \par\pard\ql\li3321\sb113\sl-253\slmult0 \up0 \expndtw-6\charscalex100 Otoaco
ustic Emissions \par\pard\qj \li1286\ri961\sb142\sl-260\slmult0\fi478 \up0 \expn
dtw-10\charscalex95 OAE are a fast, cost-eective, and frequency-specic tool
for \line \up0 \expndtw-10\charscalex96 screening auditory sensitivity in
people with disabilities \up0 \expndtw-10\charscalex91 (Evenhuis, \par\pard\qj
\li1286\ri961\sb0\sl-260\slmult0 \up0 \expndtw-8\charscalex100 1996). OAE provi
de information about the integrity of cochlear struc\up0 \expndtw-9\charscalex97
ture; that is, OAE give us information about outer hair cell function and \up0
\expndtw-10\charscalex93 inner ear micromechanics or hearing in general. \par\pa
rd\qj \li1286\ri959\sb0\sl-260\slmult0\fi478 \up0 \expndtw-7\charscalex100 OAE a
re usually present in ears with hearing thresholds in the \up0 \expndtw-10\chars
calex95 range of 30 ^35 dB HL or better. The presence of OAE indicate normal \up
0 \expndtw-9\charscalex94 functioning of outer hair cells. However, this procedu
re does not provide \up0 \expndtw-10\charscalex94 the degree or conguration of he
aring loss. \par\pard\li1286\sb10\sl-253\slmult0\fi478\tx6412\tx6761 \up0 \expnd
tw-10\charscalex96 When hearing loss is present and greater than\tab \up0
\expndtw-10\charscalex96 30\tab \up0 \expndtw-10\charscalex96 dB HL,\par\pard\
li1286\sb7\sl-253\slmult0\fi0 \up0 \expndtw-9\charscalex97 transient OAE are
absent. On the other hand, if the hearing loss\par\pard\li1286\sb6\sl-25
3\slmult0\fi0\tx2691 \up0 \expndtw-10\charscalex96 is greater than\tab \up0 \exp
ndtw-10\charscalex96 35 ^ 40 dB HL, distortion product emission OAE are\par\par
d\li1286\sb7\sl-253\slmult0\fi0 \up0 \expndtw-10\charscalex96 absent (Hall, 2000
).\par\pard\qj \li1286\ri959\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscale
x90 The presence of middle ear diseases can cause abnormal OAE nd-\line \up0 \exp
ndtw-10\charscalex96 ings (Hall, 2000; Sutton, Gleadle, & Rowe, 1996) because
middle ear \line \up0 \expndtw-9\charscalex95 pathologic conditions that may cau
se (conductive hearing loss) limit the \line \up0 \expndtw-8\charscalex100 inten
sity of sound reaching the cochlea, which in turn limits the inten-\line \up0 \e
xpndtw-9\charscalex95 sity of cochlea response. Furthermore, middle ear patholog
ic conditions \line \up0 \expndtw-7\charscalex100 limit the intensity of the ech
o that is transmitted back to the tympanic \line \up0 \expndtw-9\charscalex100 m
embrane from the cochlea, which may or may not be detected as a \line \up0 \expn
dtw-9\charscalex94 signal. Thus it is wise to rule out middle ear pathologic con
ditions before \line \up0 \expndtw-10\charscalex92 obtaining OAE. Because OAE ar
e frequency specic, they can be absent \line \up0 \expndtw-9\charscalex95 in reg
ions where hearing is greater than 40 dB HL and present in \line \up0 \

expndtw-10\charscalex97 frequency regions where hearing sensitivity is better th

an 30 dB HL in \line \up0 \expndtw-10\charscalex86 the same ear. \par\pard\ql \l
i2600\sb0\sl-253\slmult0 \par\pard\ql\li2600\sb112\sl-253\slmult0 \up0 \expndtw5\charscalex100 Auditory Brainstem Response Testing \par\pard\qj \li1286\ri961\s
b142\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex92 ABR is in widespread
use as an objective measure of cochlea \line \up0 \expndtw-10\charscalex96
and retrocochlear pathologic condition. The procedure is noninvasive \line \u
p0 \expndtw-9\charscalex95 and is not aected by sleep, sedation, or anesthesia (H
all, 2000; Maurizi
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz84\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
68}{\bkmkend Pg68}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2860 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 48\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-263\slmult0 \par\pard\qj\li1551\ri695\sb64\sl-263\slmult0 \
up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\f3\fs22 et al., 1995). ABR can
be used to obtain accurate hearing thresholds, \line \up0 \expndtw-10\charscalex
94 except for hearing losses greater than 80 dB HL in the frequency range \line
\up0 \expndtw-9\charscalex100 of 1000 ^ 4000 Hz. Because of these attributes, AB
R is often used to \line \up0 \expndtw-9\charscalex95 evaluate the hearing thres
holds of severe to profound mentally retarded \line \up0 \expndtw-10\charscalex9
3 consumers who otherwise would be untestable (Benham-Dunster & \line \up
0 \expndtw-10\charscalex97 Dunster, 1985; Smith and Simmons, 1982). However, in
some consu-\line \up0 \expndtw-8\charscalex100 mers, ABR can be absent even when
other test measures show that \line \up0 \expndtw-6\charscalex100 only a mild h
earing loss is present. It has been reported that ABRs \line \up0 \expndtw-7\cha
rscalex100 may not be detected if the lesion occurs at the brainstem level even
\line \up0 \expndtw-10\charscalex96 with normal cochlear responses (Hall, 2002;
Kraus, Ozdamar, Stein, & \line \up0 \expndtw-9\charscalex100 Reed, 1984; Maurizi
, Altissimi, Ottaviani, Paludetti, & Bambini, 1982). \line \up0 \expndtw-10\char
scalex94 Because of the fragile nature of some consumers, the need for sedation
\line \up0 \expndtw-9\charscalex96 and possibility of complications that mi
ght result was a source of \line \up0 \expndtw-9\charscalex95 concern, but
many consumers can be tested without the need for \line \up0 \expndtw10\charscalex87 sedation \up0 \expndtw-10\charscalex91 (Ray, \up0 \expndtw-10\ch
arscalex94 2002; Smyth, 1984). However, with consumers who \line \up0 \exp
ndtw-9\charscalex93 have CP, sedation is often needed (Siegenthaler, 1987), exce
pt for those \line \up0 \expndtw-9\charscalex96 whose conditions are so severe t
hat they are unable to relax their head \line \up0 \expndtw-10\charscalex96 and
neck regions \up0 \expndtw-10\charscalex91 (Ray, \up0 \expndtw-10\charscalex96
2002). ABR \up0 \expndtw-10\charscalex96 ndings are not foolproof. \par\pard
\qj \li1551\ri695\sb0\sl-270\slmult0 \up0 \expndtw-9\charscalex100 Some ABR resu
lts have been found to be at variance with behavioral \line \up0 \expndtw-10\cha
rscalex96 evaluation outcomes. ABRs may be absent even when there is normal \lin
e \up0 \expndtw-10\charscalex94 hearing sensitivity \up0 \expndtw-10\charscalex
97 (Worthington & Peters, 1980). Additionally, ABR \par\pard\ql \li1551\sb1\
sl-248\slmult0\tx6997 \up0 \expndtw-10\charscalex92 ndings can overestimate or
underestimate a hearing loss \tab \up0 \expndtw-10\charscalex93 (Gans & \p
ar\pard\ql \li1551\sb8\sl-253\slmult0 \up0 \expndtw-10\charscalex82 Gans, 1993).

\par\pard\ql \li3394\sb0\sl-253\slmult0 \par\pard\ql\li3394\sb0\sl-253\slmult0

\par\pard\ql\li3394\sb1\sl-253\slmult0 \up0 \expndtw-6\charscalex100 Middle Late
ncy Responses \par\pard\qj \li1551\ri696\sb118\sl-264\slmult0\fi478 \up0 \expndt
w-10\charscalex92 Middle latency responses (MLRs) represent responses from
the \line \up0 \expndtw-9\charscalex97 activation of the auditory pathway b
etween primary cortex and the \line \up0 \expndtw-10\charscalex92 auditory th
alamus, and these responses occur between 15 and 50 msec. \line \up0 \expndtw-9\
charscalex89 Measurement of these responses presents an advantage because
they \line \up0 \expndtw-9\charscalex96 are said to be more detectable near
thresholds (Maurizi et al., 1984). \line \up0 \expndtw-10\charscalex97 There ar
e, however, some practical concerns relating to the inuence \line \up0 \expndtw-9
\charscalex100 of maturational eects as well as test parameters, and other variab
les \line \up0 \expndtw-9\charscalex94 such as sleep or sedation may have
an impact on test outcomes. \line \up0 \expndtw-10\charscalex97 In general,
MLR testing is suggested if ABRs are absent or cannot be \line \up0 \expndtw-10
\charscalex91 obtained.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
69}{\bkmkend Pg69}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241
\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7292 \up0 \expndtw-8\charsca
lex93 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 49\par\pard\ql \li1953
\sb0\sl-276\slmult0 \par\pard\ql\li1953\sb33\sl-276\slmult0 \up0 \expndtw0\chars
calex101 \ul0\nosupersub\cf7\f8\fs24 INTERPRETATION OF TEST OUTCOMES \par\pard\q
j \li1286\ri959\sb238\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 \ul0\no
supersub\cf2\f3\fs22 To obtain more reliable and accurate results, it is best to
combine \up0 \expndtw-9\charscalex95 the three main electrophysiologic meas
ures, immittance, OAE, and \up0 \expndtw-10\charscalex92 ABR, with outcomes o
f behavioral evaluation (Table 2.3). For consumers \up0 \expndtw-6\charscalex100
who have CP and other disabilities and whose hearing is within the \up0 \expndt
w-9\charscalex100 normal range and who also have normal middle ear function,
aural \up0 \expndtw-10\charscalex97 rehabilitation would be recommended only if
communication skills are \up0 \expndtw-10\charscalex97 limited and there is nee
d to facilitate and enhance the development of \up0 \expndtw-9\charscalex92 spee
ch and language skills. Petrak (2000) described four combinations of \up0 \expnd
tw-10\charscalex92 psysiologic test outcomes as follows. \par\pard\qj \li1837\sb
0\sl-280\slmult0 \par\pard\qj\li1837\sb0\sl-280\slmult0 \par\pard\qj\li1837\ri15
96\sb4\sl-280\slmult0\tx2636 \up0 \expndtw0\charscalex104 \ul0\nosupersub\cf7\f8
\fs24 A\ul0\nosupersub\cf31\f32\fs17 BNORMAL\ul0\nosupersub\cf7\f8\fs24 ABR, A\
ul0\nosupersub\cf31\f32\fs17 BSENT\ul0\nosupersub\cf7\f8\fs24 OAE, A\ul0\nosupe
rsub\cf31\f32\fs17 BSENT\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\f
s17 COUSTIC \line\tab \up0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 R
\ul0\nosupersub\cf31\f32\fs17 EFLEXES\ul0\nosupersub\cf7\f8\fs24 , N\ul0\nosuper
sub\cf31\f32\fs17 ORMAL\ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupersub\cf31\f32\fs
17 YMPANOGRAM \par\pard\qj \li1286\ri960\sb257\sl-260\slmult0\fi478 \up0 \expndt
w-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 These outcomes typically suggest a
possible severe to profound \line \up0 \expndtw-10\charscalex96 sensorineural
hearing impairment. Behavioral audiologic evaluation is \line \up0 \expndtw-10\
charscalex100 suggested to indicate the degree and conguration of hearing loss so
\line \up0 \expndtw-9\charscalex93 that appropriate hearing devices can be sele

cted and tted. This will also \line \up0 \expndtw-10\charscalex93 help direct the
(re)habilitation and educational options to be chosen. \par\pard\ql \li1292\sb0
\sl-276\slmult0 \par\pard\ql\li1292\sb271\sl-276\slmult0 \up0 \expndtw0\charscal
ex107 \ul0\nosupersub\cf7\f8\fs24 N\ul0\nosupersub\cf31\f32\fs17 ORMAL\ul0\nosup
ersub\cf7\f8\fs24 ABR, A\ul0\nosupersub\cf31\f32\fs17 BNORMAL\ul0\nosupersub\cf
7\f8\fs24 OAE, A\ul0\nosupersub\cf31\f32\fs17 BNORMAL\ul0\nosupersub\cf7\f8\fs2
4 T\ul0\nosupersub\cf31\f32\fs17 YMPANOGRAM\ul0\nosupersub\cf7\f8\fs24 , \par\p
ard\ql \li3099\sb61\sl-207\slmult0 \up0 \expndtw0\charscalex102 A\ul0\nosupersub
\cf31\f32\fs17 BSENT\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17
COUSTIC\ul0\nosupersub\cf7\f8\fs24 R\ul0\nosupersub\cf31\f32\fs17 EFLEX \par\pa
rd\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri962\sb10\sl-260\slmult0\f
i478 \up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 These ndings sugge
st a possible middle ear pathologic condition. \up0 \expndtw-7\charscalex100 The
consumer needs medical follow-up. A repeat of immittance and \up0 \expndtw-10\c
harscalex88 OAE measures is suggested in 4 ^ 6 weeks. \par\pard\ql \li1449\sb0\s
l-218\slmult0 \par\pard\ql\li1449\sb0\sl-218\slmult0 \par\pard\ql\li1449\sb179\s
l-218\slmult0 \up0 \expndtw0\charscalex107 \ul0\nosupersub\cf7\f8\fs24 A\ul0\nos
upersub\cf31\f32\fs17 BNORMAL\ul0\nosupersub\cf7\f8\fs24 ABR, N\ul0\nosupersub\
cf31\f32\fs17 ORMAL\ul0\nosupersub\cf7\f8\fs24 OAE, N\ul0\nosupersub\cf31\f32\f
s17 ORMAL\ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupersub\cf31\f32\fs17 YMPANOGRAM
\par\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri962\sb8\sl-260\slm
ult0\fi478 \up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 These outc
omes suggest possible auditory neuropathy (Don & \line \up0 \expndtw-10\ch
arscalex95 Kwong, \up0 \expndtw-10\charscalex96 2002). Consumers typically ha
ve some hearing loss, but \line \up0 \expndtw-10\charscalex97 their word rec
ognition scores are signicantly poorer than the degree
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
70}{\bkmkend Pg70}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
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alex97 \ul0\nosupersub\cf2\f3\fs22 50\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\li1638\sb0\sl-207\slmult0\par\pard\li1638\sb0\sl-207\slmult0\par\pard\li1638\
sb0\sl-207\slmult0\par\pard\li1638\sb0\sl-207\slmult0\par\pard\li1638\sb0\sl-207
\slmult0\par\pard\li1638\sb16\sl-207\slmult0\fi2683 \up0 \expndtw-1\charscalex10
0 Table 2.3\par\pard\li1638\sb72\sl-207\slmult0\fi709 \up0 \expndtw-1\charscalex
100 Electrophysiologic Evaluation Outcomes and Management\par\pard\li1638\sb0\sl
-172\slmult0\par\pard\li1638\sb41\sl-172\slmult0\fi110\tx4251 \up0 \expndtw-1\ch
arscalex100 \ul0\nosupersub\cf32\f33\fs15 Normal\tab \up0 \expndtw-1\charscalex1
00 Comments/Action\par\pard\li1638\sb63\sl-172\slmult0\fi0\tx3863 \up0 \expndtw1\charscalex100 \ul0\nosupersub\cf33\f34\fs15 \u8226? ABR\tab \up0 \expndtw-1\
charscalex100 \u8226? No intervention\par\pard\li1638\sb94\sl-172\slmult0\fi0\
tx3863 \up0 \expndtw-1\charscalex100 \u8226? OAE\tab \up0 \expndtw-1\charscale
x100 \u8226? Intervention if there is a need to facilitate\par\pard\li1638\sb9
2\sl-172\slmult0\fi0\tx4084 \dn3 \expndtw-1\charscalex100 \u8226? Immittance\t
ab \up0 \expndtw-1\charscalex100 speech and language development\par\pard\li1712
\sb0\sl-172\slmult0\par\pard\li1712\sb0\sl-172\slmult0\par\pard\li1712\sb122\sl172\slmult0\fi0\tx3863 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf32\f33\fs
15 Abnormal\tab \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf33\f34\fs15 \u82
26? Possible severe to profound sensorineural\par\pard\li1638\sb88\sl-172\slmu

lt0\fi2446 \up0 \expndtw0\charscalex100 hearing loss\par\pard\li1638\sb93\sl-172

\slmult0\fi2225 \up0 \expndtw0\charscalex100 \u8226? Behavioral audiologic eva
luation to indicated\par\pard\li1638\sb0\sl-135\slmult0\fi0 \up0 \expndtw0\chars
calex100 \u8226? ABR\par\pard\li1638\sb0\sl-135\slmult0\fi2446 \up0 \expndtw0\
charscalex100 degree and configuration of hearing\par\pard\li1638\sb0\sl-135\slm
ult0\fi0 \up0 \expndtw0\charscalex100 \u8226? OAE\par\pard\li1638\sb0\sl-135\s
lmult0\fi2446 \up0 \expndtw0\charscalex101 impairment\par\pard\li1638\sb0\sl-135
\slmult0\fi0 \up0 \expndtw0\charscalex101 \u8226? Immittance\par\pard\li3863\s
b0\sl-135\slmult0\fi0 \up0 \expndtw-1\charscalex100 \u8226? Hearing aid select
ion and fitting\par\pard\li3863\sb58\sl-172\slmult0\fi0\tx4084 \up0 \expndtw-1\c
harscalex100 \u8226?\tab \up0 \expndtw-1\charscalex100 (Re)habilitation and educ
ational options\par\pard\ql \li1638\sb0\sl-172\slmult0 \par\pard\ql\li1638\sb0\s
l-172\slmult0 \par\pard\ql\li1638\sb0\sl-172\slmult0 \par\pard\ql\li1638\sb89\sl
-172\slmult0 \up0 \expndtw0\charscalex101 \u8226? Normal ABR \par\pard\li1638\
sb1\sl-145\slmult0\fi2225 \up0 \expndtw0\charscalex100 \u8226? Possible middle
ear pathologic condition\par\pard\li1638\sb0\sl-135\slmult0\fi0 \up0 \expndtw0\
charscalex100 \u8226? Abnormal OAE\par\pard\li1638\sb0\sl-135\slmult0\fi2225 \
up0 \expndtw0\charscalex103 \u8226? Medical referral\par\pard\li1638\sb0\sl-13
5\slmult0\fi0 \up0 \expndtw0\charscalex103 \u8226? Abnormal\par\pard\li1859\sb
0\sl-135\slmult0\fi2004 \up0 \expndtw0\charscalex100 \u8226? Repeat immittance
/OAE in 4-6 weeks\par\pard\li1859\sb0\sl-135\slmult0\fi0 \up0 \expndtw0\charscal
ex100 immittance\par\pard\li1638\sb0\sl-172\slmult0\par\pard\li1638\sb0\sl-172\s
lmult0\par\pard\li1638\sb56\sl-172\slmult0\fi0\tx3809 \up0 \expndtw0\charscalex1
01 \u8226? Normal OAE\tab \up0 \expndtw0\charscalex101 \u8226? Hearing shoul
d be monitored\par\pard\li1638\sb93\sl-172\slmult0\fi0\tx3809 \up0 \expndtw0\cha
rscalex101 \u8226? Normal\tab \up0 \expndtw0\charscalex101 \u8226? Possible
auditory neuropathy\par\pard\li1638\sb82\sl-172\slmult0\fi220\tx3809 \up0 \expnd
tw0\charscalex101 tympanogram\tab \up0 \expndtw0\charscalex101 \u8226? Medical
referral\par\pard\li1638\sb93\sl-172\slmult0\fi0\tx3809 \up0 \expndtw0\charscal
ex101 \u8226? Abnormal ABR\tab \up0 \expndtw0\charscalex101 \u8226? Possible
hearing aid evaluation/fitting after\par\pard\qj \li4029\ri2022\sb8\sl-260\slmu
lt0 \up0 \expndtw-3\charscalex100 monitoring over a period of time and when \up0
\expndtw-3\charscalex100 hearing is stable \par\pard\qj \li1551\sb0\sl-200\slmu
lt0 \par\pard\qj\li1551\ri743\sb110\sl-200\slmult0 \up0 \expndtw-6\charscalex98
\ul0\nosupersub\cf3\f4\fs16 Adapted after Petrak, M. R. (2000, August). Inte
grating physiologic technologies for hearing \line \up0 \expndtw-6\charscalex
98 evaluation in infants and small children: An overview. Unpublished handout: I
CS Medical.
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\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7302 \up0 \expndtw-8\charsca
lex92 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
\up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 51\par\pard\qj \li1286
\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri959\sb42\sl-260\slmult0 \up0 \expndtw10\charscalex93 of hearing loss would indicate. Consumers\ul0\nosupersub\cf11\f1
2\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 hearing should be monitored \up0 \exp
ndtw-10\charscalex94 over time to see if changes might occur or hearing is stabl
e. \par\pard\ql \li3708\sb0\sl-195\slmult0 \par\pard\ql\li3708\sb0\sl-195\slmult
0 \par\pard\ql\li3708\sb0\sl-195\slmult0 \par\pard\ql\li3708\sb109\sl-195\slmult
0 \up0 \expndtw0\charscalex106 \ul0\nosupersub\cf7\f8\fs24 M\ul0\nosupersub\cf31
\f32\fs17 ANAGEMENT \par\pard\qj \li1286\ri959\sb247\sl-266\slmult0\fi478 \up0 \
expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Parents or signicant others o
f consumers with hearing impair-\line \up0 \expndtw-10\charscalex94 ment usually
receive audiologic counseling. The degree, type, and con-\line \up0 \expndtw-9\
charscalex94 guration of the hearing loss as well as its impact on spe
ech and \line \up0 \expndtw-10\charscalex94 language development are explained
in simple and nontechnical terms. \line \up0 \expndtw-7\charscalex100 If there i
s evidence of a genetic component to the hearing loss from \line \up0 \expndtw-9
\charscalex97 case history information, then a referral for genetic coun
seling is \line \up0 \expndtw-10\charscalex93 warranted. Generally, behind-th
e-ear \up0 \expndtw-10\charscalex95 (BTE) hearing instruments are \par\pard\q
j \li1286\ri959\sb0\sl-263\slmult0 \up0 \expndtw-6\charscalex100 recommended for
children. The likelihood of losing a BTE hearing \line \up0 \expndtw-8\charsc
alex100 aid that is attached to an earmold would be less than that of losing a \
line \up0 \expndtw-7\charscalex100 much smaller in-the-ear (ITE) hearing aid. I
n addition, only the ear-\line \up0 \expndtw-8\charscalex100 mold in BTE hearing
aids would require changing periodically as the \line \up0 \expndtw-10\charscal
ex96 child grows. The cost of obtaining a replacement earmold is much less \line
\up0 \expndtw-7\charscalex100 than that of rebuilding or recasing an ITE hearin
g aid. Body hearing \line \up0 \expndtw-10\charscalex97 aids are not very popula
r anymore because the power output of many \line \up0 \expndtw-8\charscalex100 B
TE hearing aids is now comparable to that of body aids. To reduce \line \up0 \ex
pndtw-9\charscalex97 the chances of losing a hearing aid, otoclips can be used t
o attach the \line \up0 \expndtw-10\charscalex97 device to the consumer\ul0\nosu

persub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s clothing. The user\ul0

\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s name can be writt
en on \line \up0 \expndtw-9\charscalex97 the hearing device, especially if the c
onsumer lives in an institution, to \line \up0 \expndtw-9\charscalex100 avoid th
e risk of the device being mixed up with those of other users. \line \up0 \expnd
tw-9\charscalex100 Mix-ups are common with ITE hearing instruments that l
ook very \line \up0 \expndtw-10\charscalex95 much alike. \par\pard\qj \li1286\ri
960\sb0\sl-265\slmult0\fi478 \up0 \expndtw-10\charscalex92 The accuracy and ee
ctiveness of selecting and tting hearing \line \up0 \expndtw-10\charscalex93
devices have been revolutionized with the introduction of programmable \line \u
p0 \expndtw-9\charscalex96 digital hearing aids and speech mapping. W|th s
peech mapping, a \line \up0 \expndtw-9\charscalex92 consumer\ul0\nosupersub\cf
11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s benet from a hearing instru
ment can be measured and \line \up0 \expndtw-9\charscalex94 known before t
he devices are dispensed. Although more expensive \line \up0 \expndtw-9\ch
arscalex95 than analog hearing aids, digital hearing aids generally oer
better \line \up0 \expndtw-10\charscalex93 sound quality and can be precisely pr
ogrammed to meet the consumer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersu
b\cf2\f3\fs22 s \line \up0 \expndtw-10\charscalex94 communication needs.
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\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2854 \up0 \expndtw-10\charsc
alex96 \ul0\nosupersub\cf2\f3\fs22 52\tab \up0 \expndtw-8\charscalex96 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\ql \li3842\sb0\sl-276\slmult0 \par\pard\ql\li3842\sb60\sl-276\slmult0 \up0 \e
xpndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 REFERENCES \par\pard\ql \li15
51\sb0\sl-220\slmult0 \par\pard\ql\li1551\ri728\sb51\sl-220\slmult0\tx1790\tx179
0 \up0 \expndtw-7\charscalex97 \ul0\nosupersub\cf5\f6\fs18 American Speech-Langu
age and Hearing Association (1989). Mental retardation and \line\tab \up0 \expn
dtw-7\charscalex100 developmental disabilities curriculum guide for speech-langu
age pathologists and \line \tab \up0 \expndtw-8\charscalex92 audiologists. ASHA,
31, 94 ^96. \par\pard\ql \li1551\ri728\sb0\sl-220\slmult0\tx1790\tx1790 \up0 \e
xpndtw-7\charscalex100 Benham-Dunster, R. A., & Dunster, J. R. (1985). Hearing l
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sb0\sl-220\slmult0\tx1790 \up0 \expndtw-7\charscalex95 Bess, F. H. & Humes, L. E
. (1990). Audiology: the fundamentals. Baltimore: W|lliams & \line\tab \up0 \ex
pndtw-8\charscalex95 W|lkins. \par\pard\qj \li1551\ri729\sb0\sl-220\slmult0\tx17
90 \up0 \expndtw-7\charscalex96 Byers,V.W. & Bristow, D. C. (1990). Audiological
evaluation of nonspeaking, physically \line\tab \up0 \expndtw-8\charscalex89 ch
allenged populations. Ear and Hearing, 11(5), 382^386. \par\pard\li1551\sb16\sl207\slmult0\fi0 \up0 \expndtw-7\charscalex96 Cornacchia, L., V|gliani., & Arpini
, A. (1982). Comparison between brainstem-evoked\par\pard\li1551\sb12\sl-207\slm
ult0\fi239\tx5831\tx6186 \up0 \expndtw-8\charscalex95 response audiometry and
behavioral audiometry in\tab \up0 \expndtw-8\charscalex86 270\tab \up0 \expnd
tw-8\charscalex95 infants and children.\par\pard\li1551\sb12\sl-207\slmult0\fi
239 \up0 \expndtw-8\charscalex95 Audiology, 21, 359 ^363.\par\pard\ql \li1551\ri
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., & Roeser, R. J. (1993). Incidence of excessive impacted cerumen in \line\tab

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tal Retardation, 97, 568 ^574. \par\pard\ql \li1551\ri729\sb4\sl-216\slmult0\tx1
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he use of visual reinforcement audiometry \line\tab \up0 \expndtw-7\charscalex92
(VRA) with profound retarded residents. Mental Retardation, 15, 40 ^ 41. \line
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Rights Act of 1990, T|tle 42, U.S.C. \line\tab \up0 \expndtw-8\charscalex84 6000
^ 6083, U.S. Statutes at Large, 104, 1191^1204. \par\pard\li1551\sb28\sl-207\sl
mult0\fi0 \up0 \expndtw-7\charscalex97 Diefendorf, A. O. (2002). Detection a
nd assessment of hearing loss in infants and\par\pard\li1551\sb12\sl-207\sl
mult0\fi239\tx3449\tx6156 \up0 \expndtw-8\charscalex96 children. In J. Katz,\
tab \up0 \expndtw-8\charscalex87 (Ed.). Handbook of clinical audiology\tab \
up0 \expndtw-8\charscalex96 (5th ed.). New York:\par\pard\li1551\sb12\sl-207\s
lmult0\fi239 \up0 \expndtw-8\charscalex96 Lippincott W|lliams & W|lkins.\par\par
d\li1551\sb11\sl-207\slmult0\fi0 \up0 \expndtw-7\charscalex97 Don, M., & Kwong,
B. (2002). Auditory brainstem response: Dierential diagnosis.\par\pard\li1551\sb
13\sl-207\slmult0\fi239\tx2684\tx5341 \up0 \expndtw-8\charscalex93 In J. Katz,
\tab \up0 \expndtw-8\charscalex86 (Ed.). Handbook of clinical audiology\tab
\up0 \expndtw-8\charscalex96 (5th ed.). New York: Lippincott\par\pard\li1551\
sb12\sl-207\slmult0\fi239 \up0 \expndtw-8\charscalex96 W|lliams & W|lkins.\par\p
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alex91 Evenhuis, H. M. (1996). Dutch consensus on diagnosis and treatment of hea
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alex94 ment in children and adults with intellectual disability. Journal of Inte
llectual Disability \up0 \expndtw-8\charscalex80 Research, 40, 451^ 456. \par\pa
rd\ql \li1551\sb3\sl-207\slmult0 \up0 \expndtw-7\charscalex90 Fisch, L. (1955).
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iedrich, B. W. (1985). The state of the art in audiologic evaluation and managem
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t0\tx1790 \up0 \expndtw-6\charscalex100 Fulton, R. T. & Lamb, L. E. (1972). Acou
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D. (1993). Development of a hearing test protocol for profoundly \line\tab \up0
\expndtw-8\charscalex91 involved multi-handicapped children. Ear & Hearing, 14(2
), 128 ^140.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
73}{\bkmkend Pg73}\par\pard\li2913\sb0\sl-241\slmult0\par\pard\li2913\sb0\sl-241

\slmult0\par\pard\li2913\sb201\sl-241\slmult0\fi0\tx7300 \up0 \expndtw-8\charsca

lex92 \ul0\nosupersub\cf5\f6\fs18 Cerebral Palsy/Developmental Disabilities\tab
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xpndtw-7\charscalex95 \ul0\nosupersub\cf5\f6\fs18 Gersh, E. S. (1991). Medical c
oncerns and treatment. In E. Geralis, (Ed.), Children with \line\tab \up0 \expnd
tw-8\charscalex90 Cerebral Palsy. Bethesda, MD: Woodbine House, Inc. \par\pard\q
j \li1286\ri994\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-4\charscalex100 Green, K
. W., & Margolis, R. H. (1983). Detection of hearing loss with ipsilateral \l
ine\tab \up0 \expndtw-8\charscalex88 acoustic reex thresholds. Audiology, 22, 471
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scalex90 Hall, J.W. (2000). Handbook of otoacoustic emissions. San Diego, CA: Si
ngular Publishing. \up0 \expndtw-7\charscalex95 Hannley, M. (1984). Immittance
audiometry (pp. 57^ 83). In J. Jerger, (Ed.). Hearing \line\tab \up0 \expndt
w-8\charscalex91 disorders in adults. San Diego, CA: College-Hill. \par\pard\ql
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97 Hur, J. J. \tab \up0 \expndtw-5\charscalex100 (1997). Skills for indepen
dence for children with cerebral palsy: A \line\tab \up0 \expndtw-7\charsc
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^274. \par\pard\qj \li1286\ri994\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-7\char
scalex95 Jerger, J., Burney, P., Mauldin, L., & Crump, B. (1974). Predicting hea
ring loss from the \line\tab \up0 \expndtw-8\charscalex84 acoustic reex. Journal
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0\slmult0\fi0\tx1525\tx1525 \up0 \expndtw-7\charscalex96 Keiser, H., Montague,
J., Wold, D., Maune, S. & Pattison, D. (1981). Hearing loss \line\tab \u
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(1975). V|deoaudiometry: A possible procedure for \up0 \expndtw-8\charscal
ex88 \ul0\nosupersub\cf10\f11\fs18 \u8216?\u8216?\ul0\nosupersub\cf5\f6\fs18 di\
u8260?cult-to-test\ul0\nosupersub\cf10\f11\fs18 \u8217?\u8217? \par\pard\ql \li1
790\sb11\sl-207\slmult0 \up0 \expndtw-8\charscalex87 \ul0\nosupersub\cf5\f6\fs18
populations:Volta Review, 77, 109 ^134.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
77}{\bkmkend Pg77}\par\pard\ql \li3339\sb0\sl-368\slmult0 \par\pard\ql\li3339\sb
0\sl-368\slmult0 \par\pard\ql\li3339\sb0\sl-368\slmult0 \par\pard\ql\li3339\sb21
2\sl-368\slmult0 \up0 \expndtw0\charscalex114 \ul0\nosupersub\cf28\f29\fs32 CHAP
TER 3 \par\pard\ql \li3729\sb0\sl-368\slmult0 \par\pard\ql\li3729\sb324\sl-368\s
lmult0 \up0 \expndtw0\charscalex95 \ul0\nosupersub\cf29\f30\fs32 HIV/AIDS \par\p
ard\ql \li2050\sb0\sl-253\slmult0 \par\pard\ql\li2050\sb74\sl-253\slmult0 \up0 \
expndtw0\charscalex100 \ul0\nosupersub\cf2\f3\fs22 John M.A. Oyiborhoro, Ed.D.,

F.A.A.A., CCC-A \par\pard\ql \li3471\ri3176\sb0\sl-240\slmult0\tx3804 \up0 \expn

dtw-4\charscalex100 \ul0\nosupersub\cf6\f7\fs20 Boro Audiology Clinic \line\tab
\up0 \expndtw-4\charscalex100 Brooklyn, NY \par\pard\ql \li4250\sb7\sl-230\slmul
t0 \up0 \expndtw-9\charscalex92 and \par\pard\ql \li2581\sb10\sl-230\slmult0 \up
0 \expndtw-8\charscalex100 National Institute for People with Disabilities \par\
pard\ql \li3780\sb10\sl-230\slmult0 \up0 \expndtw-4\charscalex100 New York, NY \
par\pard\ql \li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb0\sl-230\slmult0 \p
ar\pard\ql\li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb100\sl-230\slmult0 \u
p0 \expndtw-2\charscalex100 Modes of Transmission of HIV \par\pard\ql \li2840\ri
1805\sb2\sl-240\slmult0 \up0 \expndtw0\charscalex100 HIV Infection and AIDS-Rela
ted Pathologic \up0 \expndtw0\charscalex100 Conditions \par\pard\ql \li3319\ri14
05\sb0\sl-240\slmult0 \up0 \expndtw-9\charscalex90 Some Causes of AIDS-Related D
iseases/Lesions \up0 \expndtw-9\charscalex97 Auditory Disorders Associated with
AIDS \line \up0 \expndtw-8\charscalex100 Conductive Auditory Pathologic Conditio
ns \up0 \expndtw-9\charscalex91 Causes of Sensorineural Hearing Loss in \line \u
p0 \expndtw-9\charscalex92 HIV-Positive Individuals and \par\pard\ql \li3718\sb9
\sl-230\slmult0 \up0 \expndtw-9\charscalex97 Patients with AIDS \par\pard\qj \li
3319\ri2235\sb19\sl-220\slmult0 \up0 \expndtw-9\charscalex95 Retrocochlear Patho
logic Conditions \up0 \expndtw-9\charscalex94 Auditory P300 Response \par\pard\q
l \li2840\sb12\sl-230\slmult0 \up0 \expndtw-3\charscalex100 Management \par\pard
\ql \li2840\sb10\sl-230\slmult0 \up0 \expndtw-8\charscalex100 References \par\pa
rd\ql \li2840\sb10\sl-230\slmult0 \up0 \expndtw-7\charscalex100 Suggested Readin
gs \par\pard\qj \li1286\sb0\sl-256\slmult0 \par\pard\qj\li1286\sb0\sl-256\slmult
0 \par\pard\qj\li1286\ri959\sb77\sl-256\slmult0\fi478 \up0 \expndtw-10\charscale
x100 \ul0\nosupersub\cf2\f3\fs22 Human immunodeciency virus (HIV) infection
and acquired \line \up0 \expndtw-10\charscalex96 immune deciency syndrome (AIDS
) existed for decades before 1981 \line \up0 \expndtw-10\charscalex92 when the o
ccurrence of AIDS became an epidemic (Larsen, 1998). AIDS \line \up0 \expndtw-10
\charscalex95 is undoubtedly one of world\ul0\nosupersub\cf11\f12\fs22 \u8217?\u
l0\nosupersub\cf2\f3\fs22 s most dreaded killer diseases. Since 1981 \line \up0
\expndtw-9\charscalex95 when the U.S. Centers for Disease Control and Pr
evention (CDC) \line \up0 \expndtw-9\charscalex100 in Atlanta reported and desc
ribed cases of HIV infection and patients \line \up0 \expndtw-9\charscalex100 li
ving with AIDS (CDC, 1981a), HIV infection and the disease AIDS \par\pard\ql \l
i4316\sb0\sl-207\slmult0 \par\pard\ql\li4316\sb98\sl-207\slmult0 \up0 \expndtw-8
\charscalex83 \ul0\nosupersub\cf5\f6\fs18 57 \par\pard\qj \li3067\ri2882\sb0\sl160\slmult0\fi65 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf30\f31\fs12 Aura
l Rehabilitation for People with Disabilities \line \up0 \expndtw0\charscalex100
Copyright \up0 \expndtw-2\charscalex100 2005, Elsevier Inc. All rights reserved
.
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72}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
78}{\bkmkend Pg78}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2856 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 58\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-262\slmult0 \par\pard\qj\li1551\ri696\sb66\sl-262\slmult0 \
up0 \expndtw-9\charscalex98 \ul0\nosupersub\cf2\f3\fs22 have spread rather ra
pidly throughout the world with devastating \up0 \expndtw-8\charscalex100 c
onsequences along the way. AIDS is especially widespread in \up0 \expndt
w-9\charscalex98 developing countries that are the least able to economi
cally and \up0 \expndtw-9\charscalex95 technologically combat and arrest a
spread of the epidemic. AIDS \up0 \expndtw-10\charscalex94 has decimated po
pulations and destroyed family units in these develop\up0 \expndtw-9\charscalex1
00 ing countries, especially in sub-Saharan Africa where the impact \up0
\expndtw-7\charscalex100 has been most severe. About 90% of new HIV infections
each year \up0 \expndtw-10\charscalex92 occur in developing countries (Pivot, 1
997). \par\pard\qj \li1551\ri695\sb0\sl-265\slmult0\fi478 \up0 \expndtw-10\chars
calex94 The initial cases of AIDS-related diseases were reported in homo-\line \
up0 \expndtw-9\charscalex100 sexual men who presented an unusual form of pneumon
ia caused by \line \up0 \expndtw-9\charscalex88 Pneumocystis carinii, Kaposi\u
l0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s sarcoma, and
other infections caused by \line \up0 \expndtw-10\charscalex94 opportunistic
pathogens (CDC, 1981b). The CDC (1981c) then dened \line \up0 \expndtw-8\charsc
alex100 AIDS as a disease that is at least moderately predictive of a defect in
\line \up0 \expndtw-10\charscalex96 cell-mediated immunity occurring in a person
with no known cause for \line \up0 \expndtw-9\charscalex90 diminished resistanc
e to the disease. According to the CDC, such diseases \line \up0 \expndtw-9\char
scalex88 include Kaposi\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2
\f3\fs22 s sarcoma, Pneumocystis carinii pneumonia, and serious \line \up0
\expndtw-10\charscalex88 opportunistic infections. \par\pard\qj \li1551\ri695\s
b0\sl-266\slmult0\fi478 \up0 \expndtw-10\charscalex96 HIV-infected individuals a
nd patients living with AIDS experience \line \up0 \expndtw-9\charscalex94 a wid
e spectrum of AIDS-related diseases and disabilities, some directly \line \up0 \
expndtw-6\charscalex100 as a result of HIV infection and others indirectly from
the treatment \line \up0 \expndtw-10\charscalex97 of AIDS itself or the prophyla
ctic action of HIV treatment drugs. \par\pard\qj \li1551\ri696\sb0\sl-263\slmult
0\fi478 \up0 \expndtw-9\charscalex100 Some of the disabling conditions experienc
ed by HIV-1^infected \line \up0 \expndtw-7\charscalex100 individuals and patie
nts with AIDS include cognitive and motor \line \up0 \expndtw-10\charscale
x96 function decits ( Flower & Sooy, 1987; Sahakia et al., 1995). Of more \line \
up0 \expndtw-9\charscalex100 interest to us are the auditory manifestations of A
IDS that have been \line \up0 \expndtw-9\charscalex100 well documented in the li
terature (Kohan, Rothstein, & Cohen, 1988; \line \up0 \expndtw-9\charscalex100
Lalwani & Sooy, 1992; Moazzez & Alvi, 1998; Morris & Prasad, 1990; \line \up0 \e
xpndtw-9\charscalex93 Rarey, 1990; Soucek & Michaels, 1996). The auditory
manifestations \line \up0 \expndtw-6\charscalex100 include, but are not limited
to, the following conditions and audiolo-\line \up0 \expndtw-8\charscalex100 gi
c evaluation outcomes: otitis externa, serous and chronic otitis \line \
up0 \expndtw-9\charscalex95 media, eustachian tube dysfunction, sensorineural he
aring loss, vertigo, \line \up0 \expndtw-10\charscalex95 gait problems, conducti
ve hearing loss, sudden or progressive sensori-\line \up0 \expndtw-9\charscalex9
0 neural hearing loss, tinnitus, Kaposi\ul0\nosupersub\cf11\f12\fs22 \u8217?
\ul0\nosupersub\cf2\f3\fs22 s sarcoma, nasopharyngeal mass, \line \up0 \expnd
tw-10\charscalex90 central nervous system \up0 \expndtw-10\charscalex90 (CNS)
complications, auditory brainstem \par\pard\ql \li1551\sb1\sl-244\slmult0\tx2
444\tx7182 \up0 \expndtw-10\charscalex83 response \tab \up0 \expndtw-9\charscale
x100 (ABR) abnormalities, and otoacoustic emissions \tab \up0 \expndtw-6\cha

rscalex100 (OAE) \par\pard\qj \li1551\ri696\sb3\sl-260\slmult0 \up0 \expndtw-5\c

harscalex100 abnormalities. We will return to manifestations of AIDS later in th
is \line \up0 \expndtw-10\charscalex94 chapter, but \up0 \expndtw-5\charscalex1
00 rst we will examine the nature of the killer HIV,
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
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\slmult0\par\pard\li4014\sb201\sl-241\slmult0\fi0\tx7298 \up0 \expndtw-6\charsca
lex100 \ul0\nosupersub\cf5\f6\fs18 HIV/AIDS\tab \up0 \expndtw-8\charscalex100 \u
l0\nosupersub\cf2\f3\fs22 59\par\pard\qj \li1286\sb0\sl-240\slmult0 \par\pard\qj
\li1286\ri961\sb78\sl-240\slmult0 \up0 \expndtw-9\charscalex97 the way it is
transmitted, and then its pathogenic/histopathogenic \up0 \expndtw-10\chars
calex83 consequences. \par\pard\qj \li1286\ri959\sb4\sl-260\slmult0\fi478 \up0 \
expndtw-10\charscalex92 V|ruses, in general, are nonliving organisms that
are composed \line \up0 \expndtw-10\charscalex93 of protein molecules called
ribonucleic acid \up0 \expndtw-10\charscalex93 (RNA) or deoxyribo-\par\pard
\qj \li1286\ri960\sb0\sl-260\slmult0 \up0 \expndtw-7\charscalex100 nucleic acid
(DNA). A virus is made up of either RNA or DNA, not a \line \up0 \expndtw-8\char
scalex100 combination of both. A virus made of RNA protein molecules is
\line \up0 \expndtw-9\charscalex94 referred to as a retrovirus. This virus cont
ains a self-regulatory gene that \line \up0 \expndtw-9\charscalex96 enables it t
o self-replicate (producing several copies of itself ) and also \line \up0 \exp
ndtw-9\charscalex90 causes its pathogenetic actions as it attacks and at
taches itself to the \line \up0 \expndtw-10\charscalex90 host cell. \par\pard\
qj \li1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 The hum
an immune system contains protective ghting cells \line \up0 \expndtw-9\cha
rscalex97 (phagocytes). These cells search and destroy invading killer c
ells \line \up0 \expndtw-9\charscalex100 (pathogens) to enable the human bo
dy to maintain good health. \line \up0 \expndtw-10\charscalex94 However, if
the immune system is compromised, then other opportunis-\line \up0 \expndtw-9\ch
arscalex100 tic pathogens that hitherto were not harmful become pathogenic and,
\line \up0 \expndtw-6\charscalex100 thus, harmful. HIV has a special a\u8260?nit
y for human T-helper lympho-\line \up0 \expndtw-10\charscalex95 cytes. The T-hel
per lymphocyte cells induce the most immunogenic \line \up0 \expndtw-7\char
scalex100 actions to ght o invading foreign killer cells. The pathogenic action \l
ine \up0 \expndtw-9\charscalex97 of HIV tends to deplete T-helper lymphocyte
cell counts. Reduced \line \up0 \expndtw-10\charscalex95 T-helper lymphocyt
e cell counts render the immune system weak, \line \up0 \expndtw-8\charsc
alex100 less capable of defending itself, and prone to opportunistic attack by \
line \up0 \expndtw-10\charscalex90 other pathogens. \par\pard\ql \li2283\sb0\sl276\slmult0 \par\pard\ql\li2283\sb211\sl-276\slmult0 \up0 \expndtw0\charscalex10
2 \ul0\nosupersub\cf7\f8\fs24 MODES OF TRANSMISSION OF HIV \par\pard\qj \li1286\
ri960\sb258\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupersub\c
f2\f3\fs22 Sources of transmission of HIV are displayed in Table 3.1. The \
line \up0 \expndtw-9\charscalex100 primary mode of transmission is through unpro
tected sexual contact, \line \up0 \expndtw-9\charscalex95 especially by receptiv
e anal intercourse. HIV is also transmitted through \line \up0 \expndtw-8\charsc
alex100 transfusion of infected blood; needle-sharing among intravenous \l
ine \up0 \expndtw-10\charscalex92 drug abusers; and transplacental, peri
natal \up0 \expndtw-9\charscalex100 (i.e., during natural \par\pard\ql \li12

86\sb6\sl-253\slmult0\tx3434 \up0 \expndtw-10\charscalex95 delivery), or postn

atal \tab \up0 \expndtw-9\charscalex100 (during breast feeding) transmittal
from an \par\pard\qj \li1286\ri959\sb2\sl-260\slmult0 \up0 \expndtw-9\charscale
x94 HIV-infected mother to her child. It has been suggested that about
\line \up0 \expndtw-10\charscalex94 50% of people infected with HIV will
develop full-blown AIDS \par\pard\li1286\sb16\sl-253\slmult0\fi0\tx2017\tx236
4\tx2956\tx3855 \up0 \expndtw-9\charscalex100 within\tab \up0 \expndtw-9\charsca
lex100 10\tab \up0 \expndtw-10\charscalex83 years\tab \up0 \expndtw-10\charscale
x90 (Watson,\tab \up0 \expndtw-9\charscalex100 1996). However, with the new
drugs\par\pard\qj \li1286\ri961\sb0\sl-260\slmult0 \up0 \expndtw-9\charscalex95
now available, people are living much longer and more productive \up0
\expndtw-9\charscalex95 lives than ever before because the development of
full-blown AIDS \up0 \expndtw-10\charscalex91 is being delayed considerably.
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rd\ql \li4327\sb0\sl-207\slmult0 \par\pard\ql\li4327\sb0\sl-207\slmult0 \par\par
d\ql\li4327\sb0\sl-207\slmult0 \par\pard\ql\li4327\sb0\sl-207\slmult0 \par\pard\
ql\li4327\sb0\sl-207\slmult0 \par\pard\ql\li4327\sb0\sl-207\slmult0 \par\pard\ql
\li4327\sb0\sl-207\slmult0 \par\pard\ql\li4327\sb0\sl-207\slmult0 \par\pard\ql\l
i4327\sb0\sl-207\slmult0 \par\pard\ql\li4327\sb0\sl-207\slmult0 \par\pard\ql\li4
327\sb0\sl-207\slmult0 \par\pard\ql\li4327\sb0\sl-207\slmult0 \par\pard\ql\li432
7\sb0\sl-207\slmult0 \par\pard\ql\li4327\sb0\sl-207\slmult0 \par\pard\ql\li4327\
sb0\sl-207\slmult0 \par\pard\ql\li4327\sb0\sl-207\slmult0 \par\pard\ql\li4327\sb
0\sl-207\slmult0 \par\pard\ql\li4327\sb154\sl-207\slmult0 \up0 \expndtw-8\charsc
alex93 Table 3.1 \par\pard\ql \li2504\sb73\sl-207\slmult0 \up0 \expndtw0\charsca
lex100 People at Risk of Contracting HIV Infection and AIDS \par\pard\ql \li1551
\sb133\sl-207\slmult0 \up0 \expndtw-8\charscalex91 1. Sexually active homosexual
men \par\pard\ql \li1551\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex92 2. Bi
sexual men and their partners (male/female) \par\pard\ql \li1551\sb13\sl-207\slm
ult0 \up0 \expndtw-8\charscalex89 3. Intravenous drug users (who share needles)
\par\pard\ql \li1551\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex95 4. Heteros
exual men and women (with multiple partners) \par\pard\ql \li1551\sb13\sl-207\sl
mult0 \up0 \expndtw-8\charscalex92 5. People who receive blood transfusions (wit
h unscreened blood) \par\pard\ql \li1551\sb13\sl-207\slmult0 \up0 \expndtw-8\cha
rscalex93 6. People who take blood products (made from tainted blood) \par\pard\
ql \li1551\sb13\sl-207\slmult0 \up0 \expndtw-7\charscalex95 7. People who have s
exual contacts with HIV-infected individuals or patients with AIDS \par\pard\ql
\li1551\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex96 8. Newborns of HIV-infe
cted mothers \par\pard\ql \li1551\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex
92 9. Immigrants from areas with many cases of AIDS. \par\pard\qj \li1551\ri746\
sb179\sl-200\slmult0 \up0 \expndtw-6\charscalex96 \ul0\nosupersub\cf3\f4\fs16 Ad
apted from Cooper, P. G. (2000). AIDS: Risk factors and prevention of transmissi
on. Pamphlet: \up0 \expndtw-7\charscalex93 Gale Group.
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
81}{\bkmkend Pg81}\par\pard\li4014\sb0\sl-241\slmult0\par\pard\li4014\sb0\sl-241
\slmult0\par\pard\li4014\sb201\sl-241\slmult0\fi0\tx7300 \up0 \expndtw-6\charsca
lex100 \ul0\nosupersub\cf5\f6\fs18 HIV/AIDS\tab \up0 \expndtw-8\charscalex100 \u
l0\nosupersub\cf2\f3\fs22 61\par\pard\qj \li2161\sb0\sl-260\slmult0 \par\pard\qj
\li2161\ri1881\sb62\sl-260\slmult0\tx2750 \up0 \expndtw0\charscalex105 \ul0\nosu
persub\cf7\f8\fs24 HIV INFECTION AND AIDS-RELATED \line\tab \up0 \expndtw0\chars
calex102 PATHOLOGIC CONDITIONS \par\pard\qj \li1286\ri961\sb260\sl-260\slmult0\f
i478 \up0 \expndtw-10\charscalex91 \ul0\nosupersub\cf2\f3\fs22 Watson (1996) lis
ted three main areas into which indicators of AIDS \up0 \expndtw-9\charscalex87
as a disease can be classied. They are (1) infectious diseases, (2) neoplastic \u
p0 \expndtw-10\charscalex87 diseases, and (3) others. \par\pard\qj \li1286\ri959
\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91 First, AIDS-related infe
ctious diseases include, but are by no means \line \up0 \expndtw-9\charscalex100
limited to, P. carinii pneumonia (more than 60% of patients with AIDS \line \up
0 \expndtw-9\charscalex94 develop this disease), cytomegalovirus retinitis, esop
hageal candidiasis, \line \up0 \expndtw-9\charscalex95 cryptosporidiosis, and is
osporiasis; all of these conditions are accompa-\line \up0 \expndtw-10\charscale
x94 nied by diarrhea persisting for more than 1 month and toxoplasmosis of \line
\up0 \expndtw-9\charscalex90 the brain. Second, neoplastic disease forms
include Kaposi\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s
sarcoma, \line \up0 \expndtw-10\charscalex95 which is described as the most co
mmon malignant tumor and manifes-\line \up0 \expndtw-7\charscalex100 tation in
patients with AIDS, primary lymphoma of the brain, and \line \up0 \expndtw9\charscalex100 non-Hodgkin\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\
cf2\f3\fs22 s lymphoma. Third, other indicators of AIDS include \line \up0
\expndtw-10\charscalex96 HIV encephalopathy or what is also referred to as AIDS
dementia, the \line \up0 \expndtw-10\charscalex97 HIV wasting syndrome, and a C

D4 count of less than 200 T-helper \par\pard\li1286\sb10\sl-253\slmult0\fi0\t

x3004\tx3870\tx4807\tx5339\tx6327 \up0 \expndtw-9\charscalex94 lymphocytes/mm\ul
0\super\cf34\f35\fs23 3\tab \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3
\fs22 (a CD4\tab \up0 \expndtw-10\charscalex94 count of\tab \up0 \expndtw-10\c
harscalex83 1000\tab \up0 \expndtw-9\charscalex94 cells/mm\ul0\super\cf34\f35\fs
23 3\tab \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 represents a
n\par\pard\qj \li1286\ri960\sb0\sl-260\slmult0\fi0 \up0 \expndtw-9\charscalex100
absolute helper lymphocyte count). When the CD4 count is less than \line \up0
\expndtw-7\charscalex100 200/mm\ul0\super\cf34\f35\fs23 3\ul0\nosupersub\cf2\f3\
fs22 , the development of full-blown AIDS in the HIV-infected \line \up0 \ex
pndtw-9\charscalex97 individual is imminent if prophylactic action is not taken
immediately. \par\pard\ql \li1872\sb0\sl-218\slmult0 \par\pard\ql\li1872\sb0\sl218\slmult0 \par\pard\ql\li1872\sb57\sl-218\slmult0 \up0 \expndtw-1\charscalex10
0 \ul0\nosupersub\cf7\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 OME\ul0\nosupersub\
cf7\f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 AUSES OF\ul0\nosupersub\cf7\f8\fs24
AIDS-R\ul0\nosupersub\cf31\f32\fs17 ELATED\ul0\nosupersub\cf7\f8\fs24 D\ul0\no
supersub\cf31\f32\fs17 ISEASES\ul0\nosupersub\cf7\f8\fs24 /L\ul0\nosupersub\cf31
\f32\fs17 ESIONS \par\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri9
59\sb8\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3
\fs22 Infections in HIV-infected individuals are caused by opportunistic \up0 \e
xpndtw-9\charscalex96 pathogens, which may be viruses, fungi, or bacteria. In in
dividuals with \up0 \expndtw-10\charscalex95 noncompromised immune systems, thes
e numerous pathogens can be \up0 \expndtw-9\charscalex96 found in the body but a
re not harmful because they are unable to infect \up0 \expndtw-8\charscalex100 t
heir host cells. If the immune system is compromised, infection may \up0 \expndt
w-10\charscalex96 occur because of the opportunity provided by the weakened or a
ltered \up0 \expndtw-10\charscalex97 physiologic condition of the host. \par\par
d\qj \li1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 HIV pa
thogenic activities weaken or suppress the immune system \line \up0 \expndtw-9\c
harscalex97 in infected individuals. This provides the opportunity for ot
herwise \line \up0 \expndtw-9\charscalex100 nonharmful pathogens to become patho
genic by attacking host cells, \line \up0 \expndtw-10\charscalex94 thus causing
infections and life-threatening complications \up0 \expndtw-9\charscalex100
(Grimaldi \par\pard\qj \li1286\ri960\sb0\sl-260\slmult0 \up0 \expndtw-8\charsca
lex100 et al., 1993; Kohan et al., 1988; Pappas, Roland, Lin, Lai, & Hillman, \l
ine \up0 \expndtw-9\charscalex95 1995). Hearing impairment is one of the
manifestations associated
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\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2857 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 62\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri695\sb70\sl-260\slmult0 \
up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 with HIV infection a
nd AIDS, which is caused by the actions of \line \up0 \expndtw-10\charsc
alex95 opportunistic pathogens. These pathogens include cytomegalovirus \li
ne \up0 \expndtw-10\charscalex96 (CMV), which is considered to be the most oppor
tunistic pathogen, \par\pard\qj \li1551\ri695\sb0\sl-264\slmult0 \up0 \expndtw-9
\charscalex82 P. carinii, Staphylococcus aureus, Mycobacterium tuberculosis,

and Toxoplasma \line \up0 \expndtw-9\charscalex92 gondii. Other infections, s

uch as herpes simplex, Ramsay Hunt syn-\line \up0 \expndtw-10\charscalex95
drome, or herpes zoster oticus, caused by opportunistic pathogens are \line \up
0 \expndtw-9\charscalex96 also seen (Bankaitis & Keith, 1995; Grimaldi et al., 1
993; Pappas et al., \line \up0 \expndtw-10\charscalex95 1995). Individuals with
Ramsay Hunt syndrome or herpes zoster oticus \line \up0 \expndtw-9\charscalex94
may have ipsilateral facial paralysis, sensorineural hearing loss, tinnitus, \li
ne \up0 \expndtw-9\charscalex100 and vertigo (Watson, 1996). Although most form
s of otitis media that \line \up0 \expndtw-7\charscalex100 occur in HIV-infected
and non^HIV-infected individuals and patients \line \up0 \expndtw-9\charscalex9
0 with AIDS are caused by the usual pathogens such as Streptococcus \l
ine \up0 \expndtw-10\charscalex82 pneumoniae, Haemophilus inuenzae, and Morax
ella catarrhalis \up0 \expndtw-10\charscalex90 (Gherman, \par\pard\ql \li1551\s
b3\sl-253\slmult0\tx3232\tx7332 \up0 \expndtw-10\charscalex96 Ward, & Bassis,
\tab \up0 \expndtw-9\charscalex100 1998; Kohan, Hammerschlag, & Holliday, \t
ab \up0 \expndtw-10\charscalex83 1990; \par\pard\qj \li1551\ri696\sb0\sl-264\slm
ult0 \up0 \expndtw-9\charscalex95 Lalwani & Sooy, 1992), otitis media and mastoi
ditis caused by P. carinii \line \up0 \expndtw-9\charscalex97 have been report
ed as opportunistic infections that are unique to \line \up0 \expndtw-10\
charscalex97 patients with AIDS (Breda, Hammershlag, Gigliotti, & Schinella, 199
8; \line \up0 \expndtw-9\charscalex93 Gherman et al., 1988; Morris & Prasa
d, 1990; Watson, 1996). Otitis \line \up0 \expndtw-9\charscalex94 media may
also result from eustachian tube dysfunction caused by \line \up0 \expnd
tw-10\charscalex94 obstructions from AIDS-related nasopharyngeal tumors \up0
\expndtw-10\charscalex94 (Lalwani & \par\pard\ql \li1551\sb24\sl-253\slmult0 \
up0 \expndtw-10\charscalex92 Sooy, 1992; Moazzez & Alvi, 1998). \par\pard\ql \li
2347\sb0\sl-276\slmult0 \par\pard\ql\li2347\sb0\sl-276\slmult0 \par\pard\ql\li23
47\sb56\sl-276\slmult0 \up0 \expndtw0\charscalex104 \ul0\nosupersub\cf7\f8\fs24
A\ul0\nosupersub\cf31\f32\fs17 UDITORY\ul0\nosupersub\cf7\f8\fs24 D\ul0\nosuper
sub\cf31\f32\fs17 ISORDERS\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32
\fs17 SSOCIATED WITH\ul0\nosupersub\cf7\f8\fs24 AIDS \par\pard\qj \li1551\ri694
\sb255\sl-263\slmult0\fi478 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3
\fs22 W|th better antiretroviral drugs and management of people with \line \up0
\expndtw-2\charscalex100 HIV infection and AIDS, they are living longer, but mor
tality from \line \up0 \expndtw-9\charscalex95 AIDS remains at nearly 100%
(Moazzez & Alvi, 1998). In addition \line \up0 \expndtw-9\charscalex95 to
living longer, HIV-infected individuals can have productive lives. \line
\up0 \expndtw-8\charscalex100 The spectrum of disorders associated with HIV-1 in
fection and AIDS \line \up0 \expndtw-9\charscalex98 calls for a multidisciplinar
y approach and therefore the involvement of \line \up0 \expndtw-9\charscalex95 p
ractitioners for other specialties and subspecialties such as audiology, \line \
up0 \expndtw-10\charscalex94 speech-language pathology, otolaryngology, neurolog
y, ophthalmology, \line \up0 \expndtw-9\charscalex96 psychiatry, and gastroenter
ology (Larsen, 1998). To function well as a \line \up0 \expndtw-10\charscalex95
team player, the audiologist should be knowledgeable and be aware of \line \up0
\expndtw-10\charscalex95 the auditory anomalies that are associated with HIV in
fection and AIDS \line \up0 \expndtw-10\charscalex92 and the management roles th
at might be needed.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg

83}{\bkmkend Pg83}\par\pard\li4014\sb0\sl-241\slmult0\par\pard\li4014\sb0\sl-241
\slmult0\par\pard\li4014\sb201\sl-241\slmult0\fi0\tx7294 \up0 \expndtw-6\charsca
lex100 \ul0\nosupersub\cf5\f6\fs18 HIV/AIDS\tab \up0 \expndtw-7\charscalex100 \u
l0\nosupersub\cf2\f3\fs22 63\par\pard\qj \li1286\sb0\sl-256\slmult0 \par\pard\qj
\li1286\ri961\sb49\sl-256\slmult0\fi478 \up0 \expndtw-10\charscalex95 Auditory d
isorders and their audiologic correlates associated with \up0 \expndtw-10\charsc
alex95 HIV/AIDS are displayed in Table 3.2. As can be observed, auditory dis\up0
\expndtw-9\charscalex92 orders and complaints constitute a signicant aspect of t
he consequences \up0 \expndtw-6\charscalex100 of HIV infection and AIDS. Auditor
y disorders associated with HIV/ \up0 \expndtw-10\charscalex97 AIDS may not alwa
ys be caused directly by HIV, but occur as a result \up0 \expndtw-10\charscalex9
4 of the pathogenic actions of the virus. \par\pard\qj \li1286\ri960\sb1\sl-260\
slmult0\fi478 \up0 \expndtw-10\charscalex92 The occurrence of conductive, se
nsorineural, and retrocochlear \line \up0 \expndtw-6\charscalex100 pathologic
conditions in HIV infected individuals and patients living \line \up0 \expndtw-9
\charscalex94 with AIDS is well documented (Breda et al., 1988; Gherman et al.,
1988; \line \up0 \expndtw-9\charscalex93 Grimaldi et al., 1993; Kohan et al., 19
88; Real, Thomas, & Gerwin, 1987; \line \up0 \expndtw-10\charscalex91 Smith & Ca
nalis, 1989; Soucek & Michaels, 1996; T|mon & Walsh, 1989). \line \up0 \expndtw10\charscalex94 However, because of more life-threatening events due to complica
tions \line \up0 \expndtw-9\charscalex98 caused by opportunistic infections
in HIV-infected individuals and \line \up0 \expndtw-9\charscalex98 patients w
ith AIDS, the auditory pathologic conditions and their audio-\line \up0 \expndtw
-9\charscalex100 logic correlates often take a secondary position and may theref
ore be \line \up0 \expndtw-9\charscalex100 under-reported so their occurrence ma
y be higher than studies show \line \up0 \expndtw-9\charscalex93 (Bankaitis & Ke
ith, 1995; Kwartler et al., 1991; Soucek & Michaels, 1996; \line \up0 \expndtw-1
0\charscalex91 T|mon & Walsh, 1989). \par\pard\ql \li1964\sb0\sl-207\slmult0 \pa
r\pard\ql\li1964\sb0\sl-207\slmult0 \par\pard\ql\li1964\sb150\sl-207\slmult0 \up
0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 C\ul0\nosupersub\cf31\f32\
fs17 ONDUCTIVE\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UDITOR
Y\ul0\nosupersub\cf7\f8\fs24 P\ul0\nosupersub\cf31\f32\fs17 ATHOLOGIC\ul0\nosup
ersub\cf7\f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 ONDITIONS \par\pard\qj \li1286
\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb13\sl-258\slmult0\fi478 \up0 \ex
pndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Auditory disorders of the oute
r and middle ear due to complica-\line \up0 \expndtw-9\charscalex97 tions of H
IV infection include otitis externa; aural polyps; Kaposi\ul0\nosupersub\c
f11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s \line \up0 \expndtw-9\charscal
ex100 sarcoma; non-Hodgkin\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\
cf2\f3\fs22 s lymphoma; eustachian tube dysfunction; \line \up0 \expndtw-9\c
harscalex100 serous, chronic, and acute otitis media; tympanic membrane perfora\line \up0 \expndtw-9\charscalex93 tion; ossicular discontinuity; cholesteatom
a; and nasopharyngeal neo-\line \up0 \expndtw-10\charscalex96 plasms (Breda
et al., 1988; Kohan et al., 1988; Lalwani & Sooy, 1992; \line \up0 \expndtw-9\ch
arscalex91 Moazzez & Alvi, 1998; Rarey, 1990). These disease processes
aect \line \up0 \expndtw-7\charscalex100 audiologic ndings. It is important there
fore for the audiologist to be \line \up0 \expndtw-10\charscalex94 knowledgeable
about the patient\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs
22 s pathophysiology and possible audio-\line \up0 \expndtw-8\charscalex100 logi
c outcomes as a result of their manifestation in the auditory \line \u
p0 \expndtw-10\charscalex90 mechanism. \par\pard\qj \li1286\ri960\sb1\sl-260\slm
ult0\fi478 \up0 \expndtw-10\charscalex95 Otitis externa is a malignant dise
ase process that aects the \line \up0 \expndtw-9\charscalex97 cartilaginous
portion of the external auditory canal in HIV-infected \line \up0 \expndtw
-7\charscalex100 individuals. Chronic otitis externa infection is usually
caused by \line \up0 \expndtw-9\charscalex92 Pseudomonas aeruginosa (Moazzez
& Alvi, 1998). The incidence of otitis \line \up0 \expndtw-9\charscalex92 extern
a in individuals with AIDS is generally not higher than in
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mkstart Pg84}{\bkmkend Pg84}\par\pard\ql \li6544\sb0\sl-207\slmult0 \par\pard\ql
\li6544\sb0\sl-207\slmult0 \par\pard\ql\li6544\sb0\sl-207\slmult0 \par\pard\ql\l
i6544\sb0\sl-207\slmult0 \par\pard\ql\li6544\sb0\sl-207\slmult0 \par\pard\ql\li6
544\sb0\sl-207\slmult0 \par\pard\ql\li6544\sb0\sl-207\slmult0 \par\pard\ql\li654
4\sb0\sl-207\slmult0 \par\pard\ql\li6544\sb0\sl-207\slmult0 \par\pard\ql\li6544\
sb0\sl-207\slmult0 \par\pard\ql\li6544\sb0\sl-207\slmult0 \par\pard\ql\li6544\sb
0\sl-207\slmult0 \par\pard\ql\li6544\sb145\sl-207\slmult0 \up0 \expndtw-8\charsc
alex94 \ul0\nosupersub\cf5\f6\fs18 Table 3.2 \par\pard\ql \li5039\sb73\sl-207\sl
mult0 \up0 \expndtw0\charscalex100 Auditory Disorders Associated with HIV/AIDS \
par\pard\li1958\sb133\sl-207\slmult0\fi509\tx4768\tx7367 \up0 \expndtw-8\charsca
lex95 External Ear\tab \up0 \expndtw-8\charscalex95 Middle Ear\tab \up0 \expndtw
-8\charscalex95 Inner Ear\par\pard\li1958\sb80\sl-207\slmult0\fi0\tx4170\tx6463
\up0 \expndtw-8\charscalex95 Otitis externa\tab \up0 \expndtw-8\charscalex95 Eus
tachian tube dysfunction\tab \up0 \expndtw-8\charscalex95 Vertigo\par\pard\li195
8\sb12\sl-207\slmult0\fi0\tx4170\tx6463 \up0 \expndtw-8\charscalex95 Aural polyp
s\tab \up0 \expndtw-8\charscalex95 Serous/acute otitis media\tab \up0 \expndtw-8
\charscalex95 Imbalance\par\pard\li1958\sb12\sl-207\slmult0\fi0\tx4170\tx6463 \u
p0 \expndtw-8\charscalex95 Kaposi\ul0\nosupersub\cf10\f11\fs18 \u8217?\ul0\nosup
ersub\cf5\f6\fs18 s sarcoma\tab \up0 \expndtw-8\charscalex95 Cholesteatoma\tab \
up0 \expndtw-8\charscalex95 Tinnitus\par\pard\li1958\sb0\sl-207\slmult0\par\pard
\li1958\sb24\sl-207\slmult0\fi0\tx6463 \up0 \expndtw-8\charscalex95 Non-Hodgkin\
ul0\nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s lymphoma
N
asopharyngeal tumors\tab \up0 \expndtw-8\charscalex95 Endolymphatic hydrops\par\
pard\li1958\sb12\sl-207\slmult0\fi0\tx4171\tx6463 \up0 \expndtw-8\charscalex95 C
onductive hearing loss\tab \up0 \expndtw-8\charscalex95 Ossicular discontinuity\
tab \up0 \expndtw-8\charscalex95 Abnormal ABR\par\pard\li4170\sb13\sl-207\slmult
0\fi0\tx6463 \up0 \expndtw-8\charscalex94 Abnormal OAE\tab \up0 \expndtw-8\chars
calex94 Abnormal OAE\par\pard\li4170\sb12\sl-207\slmult0\fi0\tx6463 \up0 \expndt
w-8\charscalex94 Tympanic membrane\tab \up0 \expndtw-8\charscalex94 Sudden and/o
r progressive\par\pard\li4170\sb12\sl-207\slmult0\fi180\tx6463 \up0 \expndtw-8\c
harscalex94 perforation\tab \up0 \expndtw-8\charscalex94 Sensorineural hearing l
oss\par\pard\li4170\sb13\sl-207\slmult0\fi0\tx6463 \up0 \expndtw-8\charscalex94
Conductive hearing loss\tab \up0 \expndtw-8\charscalex94 Sensorineural hearing l
oss (SNHL)
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{\shp {\*\shpinst\shpleft1958\shptop3721\shpright9230\shpbottom3741\shpfhdr0\shp
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
85}{\bkmkend Pg85}\par\pard\li4014\sb0\sl-241\slmult0\par\pard\li4014\sb0\sl-241
\slmult0\par\pard\li4014\sb201\sl-241\slmult0\fi0\tx7290 \up0 \expndtw-5\charsca
lex100 \ul0\nosupersub\cf5\f6\fs18 HIV/AIDS\tab \up0 \expndtw-7\charscalex100 \u
l0\nosupersub\cf2\f3\fs22 65\par\pard\qj \li1286\sb0\sl-258\slmult0 \par\pard\qj
\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw-10\charscalex94 individuals with
noncompromised immune systems (Kohan et al., 1988; \line \up0 \expndtw-9\charsc
alex95 Lalwani & Sooy, 1992). Thus it has been suggested that otitis externa is
\line \up0 \expndtw-5\charscalex100 perhaps not exactly a manifestation of AIDS,
but rather that it may \line \up0 \expndtw-9\charscalex97 represent an incident
al auditory disorder that is present in HIV-positive \line \up0 \expndtw-10\char
scalex97 individuals and persons with AIDS (Morris & Prasad, 1990). However, \li
ne \up0 \expndtw-10\charscalex93 Moazzez and Alvi (1988) suggested that im
munocompromised indi-\line \up0 \expndtw-7\charscalex100 viduals with HIV/AIDS
may be more predisposed to malignant otitis \line \up0 \expndtw-9\charscalex94 e
xterna. In addition to reporting severe progressive pain, individuals \li
ne \up0 \expndtw-9\charscalex96 with otitis externa infection also complain of a
hearing loss (Moazzez & \line \up0 \expndtw-10\charscalex96 Alvi, 1998). This m
ay possibly be conductive because of the presence \line \up0 \expndtw-8\charscal
ex100 of excessive or impacted and microbe-infested purulent debris in the \line
\up0 \expndtw-9\charscalex96 external ear canal. Medical referral should
be made for ear canal \line \up0 \expndtw-10\charscalex97 debridement and an
tibiotic treatment (Moazzez & Alvi, 1998; Morris & \line \up0 \expndtw-10\charsc
alex81 Prasad, 1990). \par\pard\qj \li1286\ri959\sb1\sl-260\slmult0\fi478 \up0 \
expndtw-8\charscalex100 Kaposi\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupers
ub\cf2\f3\fs22 s sarcoma is considered to be the most common malig-\line \up0 \e
xpndtw-9\charscalex100 nant tumor in immunocompromised individuals with AI
DS, about \line \up0 \expndtw-10\charscalex85 20,000 \up0 \expndtw-9\charscalex
100 times more common than in the nonimmunocompromised \line \up0 \expndtw
-10\charscalex94 population (Moazzez & Alvi, 1998; Noel et al., 1996). Kaposi\ul
0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s sarcoma \line \u
p0 \expndtw-6\charscalex100 occurs mostly in the external ear of individuals wit
h AIDS. Because \line \up0 \expndtw-10\charscalex95 of the involvement of the pi
nna, ear canal, tympanic membrane, eusta-\line \up0 \expndtw-10\charscalex94 chi
an tube, and the nasopharynx, Kaposi\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\no
supersub\cf2\f3\fs22 s sarcoma causes conductive \line \up0 \expndtw-9\charscale
x100 hearing loss (Lalwani & Sooy, 1988; Moazzez & Alvi, 1998; Morris & \line \
up0 \expndtw-10\charscalex81 Prasad, 1990). \par\pard\qj \li1286\ri959\sb0\sl-26
0\slmult0\fi478 \up0 \expndtw-5\charscalex100 Many adults with AIDS often presen
t serous otitis media with \line \up0 \expndtw-9\charscalex95 eusion (i.e., witho
ut signs of inammation of the middle ear), an occur-\line \up0 \expndtw-7\charsca

lex100 rence more common than that in the general population (Lalwani & \line \
up0 \expndtw-9\charscalex97 Sooy, 1988). Serous otitis media with eusion or secre
tory otitis media \line \up0 \expndtw-10\charscalex95 can be caused by eustachia
n tube dysfunction resulting from nasopha-\line \up0 \expndtw-10\charscalex92 ry
ngeal tumors (Morris & Prasad, 1990; Stern, Lin, & Lucente, 1990). \par\pard\qj
\li1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex100 Chronic ot
itis media with or without cholesteatoma is more com-\line \up0 \expndtw-7\chars
calex100 mon in immunocompromised persons with AIDS than in the general \line \u
p0 \expndtw-9\charscalex100 population (Moazzez & Alvi, 1998). Common causes of
chronic otitis \line \up0 \expndtw-9\charscalex91 media are opportunistic infec
tions caused by S. pneumoniae, H. inuenza, \line \up0 \expndtw-9\charscalex91 and
M. catarrhalis. Chronic otitis media and mastoiditis caused by opportu-\line \u
p0 \expndtw-9\charscalex90 nistic pathogenic action of P.carinii are not common.
However, according to \line \up0 \expndtw-9\charscalex94 Lalwani and Sooy (1992
), P. carinii, which is found in aural polyps in the \line \up0 \expndtw-9\chars
calex92 external ear canal, can spread to the middle ear space via the eustachia
n \line \up0 \expndtw-10\charscalex92 tube from an infected nasopharynx. Chronic
ear pain and mixed hearing
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
86}{\bkmkend Pg86}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2860 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 66\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\ql \li1551\sb0\sl-260\slmult0 \par\pard\ql\li1551\ri696\sb70\sl-260\slmult0\t
x2030 \up0 \expndtw-9\charscalex93 \ul0\nosupersub\cf2\f3\fs22 loss usually acco
mpany chronic otitis media. Audiologic ndings typically \line \up0 \expndtw-10\ch
arscalex92 yield abnormal tympanograms and signicantly abnormal OAEs. \line \tab
\up0 \expndtw-10\charscalex96 Depending on the hearing loss criteria used, studi
es have shown \line \up0 \expndtw-7\charscalex100 that the incidence of sensorin
eural hearing loss in HIV-positive indi-\line \up0 \expndtw-10\charscalex96 vidu
als and patients with AIDS is \up0 \expndtw-10\charscalex91 20 ^ 69% (Grim
aldi et al., 1993; \par\pard\qj \li1551\ri694\sb0\sl-264\slmult0\fi0 \up0 \ex
pndtw-10\charscalex95 Lalwani & Sooy, 1992; Sooy, 1987; Soucek & Michaels, 1996)
. Using a \line \up0 \expndtw-8\charscalex100 hearing loss criterion of worse th
an 25 dB hearing sensitivity, Lalwani \line \up0 \expndtw-10\charscalex96 & Sooy
(1992) found a 45% incidence of sensorineural hearing impair-\line \up0 \expndt
w-10\charscalex96 ment in their study, which involved immunocompromised patients
with \line \up0 \expndtw-10\charscalex92 AIDS. In a separate study Soucek and M
ichaels (1996) reported an even \line \up0 \expndtw-8\charscalex100 higher incid
ence of sensorineural hearing impairment of 69% in their \line \up0 \expndtw-9\c
harscalex100 subjects with AIDS, but they used the criterion of a worse than 20
dB \line \up0 \expndtw-9\charscalex90 hearing loss. According to Sooy (1987), se
nsorineural hearing loss appears \line \up0 \expndtw-10\charscalex96 to be more
prevalent than conductive hearing loss in HIV-infected per-\line \up0 \expndtw-9
\charscalex96 sons. This nding should be of concern to both HIV-positive individu
als \line \up0 \expndtw-7\charscalex100 and patients with AIDS and their caregiv
ers, because, except in few \line \up0 \expndtw-9\charscalex94 instances of uctu
ating sensorineural hearing loss such as in Meniere\ul0\nosupersub\cf11\f12\fs22
\u8217?\ul0\nosupersub\cf2\f3\fs22 s \line \up0 \expndtw-10\charscalex94 diseas

e, sensorineural hearing impairment is permanent. Medical inter-\line \up0 \expn

dtw-9\charscalex93 vention is essentially preventive, because there is no
known medical \line \up0 \expndtw-10\charscalex92 treatment for hearing decienci
es caused by cochlear lesions or damage \line \up0 \expndtw-10\charscalex93 to t
he hair cells, which results in sensorineural hearing loss. \par\pard\ql \li1692
\sb0\sl-207\slmult0 \par\pard\ql\li1692\sb0\sl-207\slmult0 \par\pard\ql\li1692\s
b27\sl-207\slmult0 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 C\ul
0\nosupersub\cf31\f32\fs17 AUSES OF\ul0\nosupersub\cf7\f8\fs24 S\ul0\nosupersub
\cf31\f32\fs17 ENSORINEURAL\ul0\nosupersub\cf7\f8\fs24 H\ul0\nosupersub\cf31\f3
2\fs17 EARING\ul0\nosupersub\cf7\f8\fs24 L\ul0\nosupersub\cf31\f32\fs17 OSS IN\
ul0\nosupersub\cf7\f8\fs24 HIV-P\ul0\nosupersub\cf31\f32\fs17 OSITIVE \par\pard
\ql \li2728\sb20\sl-248\slmult0 \up0 \expndtw0\charscalex107 \ul0\nosupersub\cf7
\f8\fs24 I\ul0\nosupersub\cf31\f32\fs17 NDIVIDUALS AND\ul0\nosupersub\cf7\f8\fs2
4 P\ul0\nosupersub\cf31\f32\fs17 ATIENTS WITH\ul0\nosupersub\cf7\f8\fs24 AIDS
\par\pard\qj \li1551\ri694\sb259\sl-264\slmult0\fi478 \up0 \expndtw-10\charscale
x93 \ul0\nosupersub\cf2\f3\fs22 There are three sources of AIDS-related se
nsorineural hearing \line \up0 \expndtw-9\charscalex92 impairment as suggeste
d by Soucek and Michaels (1998): (1) AIDS-\line \up0 \expndtw-9\charscale
x93 related cochlear lesions, (2) ototoxicity caused by prescribed prophylactic
\line \up0 \expndtw-9\charscalex93 drugs or medications used in the treatm
ent of AIDS-related disease \line \up0 \expndtw-9\charscalex97 conditions, an
d (3) AIDS-related lesions of the auditory pathway invol-\line \up0 \expndtw-10\
charscalex97 ving the CNS. \par\pard\ql \li3143\sb0\sl-253\slmult0 \par\pard\ql\
li3143\sb133\sl-253\slmult0 \up0 \expndtw-5\charscalex100 AIDS-Related Cochlear
Lesions \par\pard\qj \li1551\ri696\sb142\sl-260\slmult0\fi478 \up0 \expndtw-10\c
harscalex96 A weakened immune system renders the patient with AIDS more \line \u
p0 \expndtw-7\charscalex100 prone to opportunistic infections that cause meningi
tis. Meningitis is \line \up0 \expndtw-9\charscalex97 considered to be one of th
e causes of cochlear lesions, which result in
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
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lex100 \ul0\nosupersub\cf5\f6\fs18 HIV/AIDS\tab \up0 \expndtw-8\charscalex100 \u
l0\nosupersub\cf2\f3\fs22 67\par\pard\qj \li1286\sb0\sl-256\slmult0 \par\pard\qj
\li1286\ri960\sb49\sl-256\slmult0 \up0 \expndtw-9\charscalex100 sensorineural he
aring loss in patients with AIDS (Kohan et al., 1988; \up0 \expndtw-10\charscal
ex92 Morris & Prasad, 1990). Some types of meningitis caused by opportunis\up0 \
expndtw-9\charscalex96 tic pathogens are cryptococcal meningitis, tuberculous me
ningitis, bac\up0 \expndtw-9\charscalex93 terial and viral meningitis, and neuro
syphilis (Kohan et al., 1988; Kwartler \up0 \expndtw-9\charscalex92 et al., 1991
). Sudden sensorineural hearing loss has been associated with \up0 \expndtw-10\c
harscalex92 cryptococcal meningitis (Kwartler et al., 1991). \par\pard\qj \li128
6\ri959\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 In addition to me
ningogenic causes for sensorineural hearing loss, \up0 \expndtw-9\charscalex95 C
MV infection constitutes another major cause of cochlear lesions \up0 \e
xpndtw-6\charscalex100 in patients with AIDS. CMV infection of the tempo
ral bone in \up0 \expndtw-8\charscalex100 patients with AIDS impairs cochlear
function by involving the eerent \up0 \expndtw-10\charscalex94 innervation to the
cochlea (Soucek & Michaels, 1996) with inammation \up0 \expndtw-7\charscalex100

of the internal auditory canal through which the eerent bers of the \up0 \expndtw10\charscalex93 vestibulocochlear nerve bundle run. \par\pard\ql \li2151\sb0\sl253\slmult0 \par\pard\ql\li2151\sb133\sl-253\slmult0 \up0 \expndtw0\charscalex10
1 Ototoxicity from AIDS-Related Drug Therapy \par\pard\qj \li1286\ri959\sb122\sl
-260\slmult0\fi478 \up0 \expndtw-7\charscalex100 Ototoxicity from drugs used eit
her as prophylactic treatment of \line \up0 \expndtw-10\charscalex96 HIV infecti
on and/or neoplasms in patients with AIDS is another possi-\line \up0 \expndtw-9
\charscalex92 ble cause of cochlear lesions and sensorineural hearing loss (Marr
a et al., \line \up0 \expndtw-9\charscalex93 1997). Ototoxicity is dened as chemi
cally induced injury to the inner ear \line \up0 \expndtw-9\charscalex95 that ca
uses varying degrees of sensorineural hearing loss (Bankaitis & \line \up0 \exp
ndtw-10\charscalex87 Keith, 1995). \par\pard\qj \li1286\ri960\sb0\sl-260\slmult0
\fi478 \up0 \expndtw-10\charscalex95 Medical treatment of HIV infection and AIDS
relies heavily on use \line \up0 \expndtw-9\charscalex97 of drug therapy. The o
totoxic eects of new antiretrovial drugs that are \line \up0 \expndtw-10\charscal
ex97 used on an experimental basis for the treatment of patients with AIDS \line
\up0 \expndtw-9\charscalex97 are not known. Some of these drugs include,
but are not limited \line \up0 \expndtw-9\charscalex97 to, azidothymidine,
acyclovir, ethambutol, isoniazid, ganciclovir, tri-\line \up0 \expndtw-10\
charscalex94 methoprim-sulfamethoxazole, isoprenaline, ucytosine, and zidovudine
\line \up0 \expndtw-9\charscalex90 (Kohan et al., 1990; Marra et al., 1997; Sou
cek & Michaels, 1996). Because \line \up0 \expndtw-9\charscalex97 of the life-th
reatening nature of complications of AIDS, known ototoxic, \line \up0 \expndtw-9
\charscalex93 antifungal drugs such as amphotericin B, aminoglycoside antibiotic
s, and \line \up0 \expndtw-9\charscalex95 antineoplastic drugs such as erythromy
cin are often used to treat AIDS-\line \up0 \expndtw-9\charscalex93 related comp
lications or are used as preventive measures in HIV-positive \line \up0 \expndtw
-10\charscalex90 persons (Bankaitis & Keith, 1995). \par\pard\ql \li1764\sb6\sl253\slmult0\tx5731 \up0 \expndtw-6\charscalex100 Results from a study by Ko
han et al. \tab \up0 \expndtw-10\charscalex93 (1988) showed that \par\pard\q
j \li1286\ri959\sb2\sl-260\slmult0 \up0 \expndtw-9\charscalex98 sensorineural h
earing loss present in their subjects with AIDS could \line \up0 \expndtw-9\ch
arscalex97 only be explained by their exposure to known ototoxic antibi
otics \line \up0 \expndtw-10\charscalex93 such as streptomycin and aminoglyc
osides. Histopathologic \up0 \expndtw-10\charscalex97 ndings
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
88}{\bkmkend Pg88}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2860 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 68\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri697\sb70\sl-260\slmult0 \
up0 \expndtw-7\charscalex100 \ul0\nosupersub\cf2\f3\fs22 suggest that sensorin
eural hearing impairment in patients with \line \up0 \expndtw-5\charscalex
100 AIDS may be due in part to ototoxic damage to the cochlea, which \line \up0
\expndtw-10\charscalex97 is manifested in the loss of cochlear outer hai
r cells \up0 \expndtw-10\charscalex96 (Soucek & \par\pard\ql \li1551\sb6\sl-25
3\slmult0 \up0 \expndtw-10\charscalex86 Michaels, 1996). \par\pard\ql \li1821\sb
0\sl-253\slmult0 \par\pard\ql\li1821\sb214\sl-253\slmult0 \up0 \expndtw-3\charsc
alex100 AIDS-Related Lesions of the Auditory Pathway of the CNS \par\pard\qj \li

1551\ri694\sb121\sl-261\slmult0\fi478 \up0 \expndtw-6\charscalex100 In immunocom

promised patients with AIDS, the CNS is prone \line \up0 \expndtw-9\charscalex10
0 to opportunistic infections as well as to development of neoplasms in \line \u
p0 \expndtw-9\charscalex96 the central auditory pathway (Petito et al., 1986). S
oucek and Michaels \line \up0 \expndtw-10\charscalex96 (1996) suggested that da
mage to the central auditory pathways could \line \up0 \expndtw-10\charscalex93
possibly cause sensorineural hearing impairment. Neurophysiologic stu-\line \up0
\expndtw-9\charscalex94 dies of patients with AIDS who have sudden bilat
eral sensorineural \line \up0 \expndtw-9\charscalex94 hearing loss revealed
bilateral involvement of both branches of the \line \up0 \expndtw-9\charsc
alex97 vestibulocochlear cranial nerves (Grimaldi et al., 1993; Kwartler et al.
, \line \up0 \expndtw-9\charscalex91 1991; Real et al., 1987). Real et al. (1987
) investigated the possible cause \line \up0 \expndtw-9\charscalex95 of sudden
sensorineural hearing impairment in a male homosexual \line \up0 \expndtw
-9\charscalex96 with AIDS, who was exposed to opportunistic infections a
nd later \line \up0 \expndtw-10\charscalex96 developed an intracerebral hemorrh
age. They concluded that the sen-\line \up0 \expndtw-10\charscalex97 sorineural
hearing loss in their patients with AIDS was perhaps due to \line \up0 \expndtw9\charscalex96 involvement of the acoustic cranial nerve or to cryptococcal meni
ngitis. \line \up0 \expndtw-9\charscalex100 Thus acoustic cranial nerve neuropat
hy associated with HIV infection \line \up0 \expndtw-10\charscalex89 can cause s
ensorineural hearing loss. \par\pard\qj \li1551\ri696\sb0\sl-263\slmult0\fi478 \
up0 \expndtw-10\charscalex96 Many patients with AIDS often present vertigo and o
ther vestibu\up0 \expndtw-9\charscalex93 lar abnormalities such as imbalance,
ataxia, and nausea. As indicated \up0 \expndtw-9\charscalex90 earlier under c
auses of sensorineural hearing loss, vestibular abnormalities \up0 \expndtw-9\ch
arscalex97 in patients with AIDS are possibly due to involvement of the vestibul
o\up0 \expndtw-9\charscalex93 cochlear cranial nerve bundle (Grimaldi et al., 19
93; Kwartler et al., 1991) \up0 \expndtw-9\charscalex96 resulting from neoplasmi
c growths or opportunistic infection that aects \up0 \expndtw-10\charscalex93 the
internal auditory meatus. \par\pard\ql \li2551\sb0\sl-207\slmult0 \par\pard\ql\
li2551\sb0\sl-207\slmult0 \par\pard\ql\li2551\sb8\sl-207\slmult0 \up0 \expndtw0\
charscalex104 \ul0\nosupersub\cf7\f8\fs24 R\ul0\nosupersub\cf31\f32\fs17 ETROCOC
HLEAR\ul0\nosupersub\cf7\f8\fs24 P\ul0\nosupersub\cf31\f32\fs17 ATHOLOGIC\ul0\n
osupersub\cf7\f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 ONDITIONS \par\pard\qj \li
1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri696\sb10\sl-260\slmult0\fi478 \up0
\expndtw-10\charscalex100 \ul0\nosupersub\cf2\f3\fs22 One direct eect of HIV inf
ection on the CNS is the development \line \up0 \expndtw-9\charscalex95 of retro
cochlear pathologic conditions that have an impact on audiologic \line \up0 \exp
ndtw-10\charscalex93 outcomes, especially ABR ndings (Lalwani & Sooy, 1992). Sign
icantly \line \up0 \expndtw-10\charscalex94 abnormal ABR ndings obtained with HIV
-positive individuals and
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
89}{\bkmkend Pg89}\par\pard\li4014\sb0\sl-241\slmult0\par\pard\li4014\sb0\sl-241
\slmult0\par\pard\li4014\sb201\sl-241\slmult0\fi0\tx7292 \up0 \expndtw-6\charsca
lex100 \ul0\nosupersub\cf5\f6\fs18 HIV/AIDS\tab \up0 \expndtw-7\charscalex100 \u
l0\nosupersub\cf2\f3\fs22 69\par\pard\qj \li1286\sb0\sl-258\slmult0 \par\pard\qj
\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw-10\charscalex97 patients with AI
DS have been attributed to complications of HIV infec-\line \up0 \expndtw-9\char

scalex97 tion and AIDS (Birchall, W|ght, French, Cockbain, & Smith, 1992
; \line \up0 \expndtw-10\charscalex92 Welkoborsky & Lowitzsch, 1992). ABR measur
es the sequence of neural \line \up0 \expndtw-9\charscalex96 activity from the v
estibulocochlear nerve bundle to the pons level of the \line \up0 \expndtw-9\cha
rscalex92 brainstem. Waves I and II are generated from the acoustic nerve wherea
s \line \up0 \expndtw-10\charscalex95 other waves are generated from other actio
ns of the brainstem. ABR is \line \up0 \expndtw-9\charscalex95 quite sensitive a
nd reliable in assessing and detecting pathologic condi-\line \up0 \expndtw-9\ch
arscalex92 tions of the acoustic nerve and the brainstem such as acoustic neurom
as, \line \up0 \expndtw-9\charscalex92 demyelinating and degenerative diseases,
and vascular lesions (Bankaitis \line \up0 \expndtw-10\charscalex96 & Keith, 199
5). ABR ndings are usually interpreted on the basis of an \line \up0 \expndtw-9\c
harscalex92 analysis of absolute latencies of waves I, II, and V; the interpeak
latencies \line \up0 \expndtw-9\charscalex94 of waves I^III, III^V, and I^V; and
the amplitude ratio of waves V:I, which \line \up0 \expndtw-10\charscalex96 are
then compared with normative test data (Clemins & McGee, 1979; \line \up0 \expn
dtw-8\charscalex100 Clemins & Mitchell, 1977; Daly, Roeser, Aung, & Daly, 1997).
These \line \up0 \expndtw-10\charscalex97 normative data sometimes vary from on
e clinic to another due to their \line \up0 \expndtw-10\charscalex90 specic clini
cal procedures. \par\pard\qj \li1286\ri960\sb1\sl-260\slmult0\fi478 \up0 \expndt
w-10\charscalex95 HIV/AIDS-related pathologic conditions in the central au
ditory \line \up0 \expndtw-10\charscalex93 pathway of CNS such as acoustic neuro
ma and cryptococcal meningitis, \line \up0 \expndtw-9\charscalex95 which often i
nvolves the vestibulocochlear nerve bundle, yield abnormal \line \up0 \expndtw-9
\charscalex91 ABRs that are observed as delays in interpeak latencies and amplit
udes of \line \up0 \expndtw-10\charscalex91 individual waves. Results from s
everal studies \up0 \expndtw-10\charscalex91 (Birchall et al., \up0 \expndtw10\charscalex82 1992; \par\pard\qj \li1286\ri959\sb2\sl-258\slmult0 \up0 \expndt
w-9\charscalex100 Lalwani & Sooy, 1992; Welkoborsky & Lowitzsch, 1992) indicate
that \line \up0 \expndtw-9\charscalex100 HIV infection and complications of
AIDS directly compromise the \line \up0 \expndtw-9\charscalex98 integrity of
ABR readings with signicant delays at interpeak latencies \line \up0 \expndtw-10\
charscalex95 between waves III and V. It should be noted, however, that the conc
lu-\line \up0 \expndtw-9\charscalex100 sions of some studies are contradictory.
Not all HIV-infected patients \line \up0 \expndtw-9\charscalex100 who have not d
eveloped full-blown AIDS present abnormal ABR nd-\line \up0 \expndtw-6\charscalex
100 ings (Iragui, Kalmijin, Thal, Grant, & HNRC Group, 1994; Madriz & \line \up0
\expndtw-9\charscalex94 Herrera, 1995; Ragazzoni et al., 1993). According to Ba
nkaitis and Keith \line \up0 \expndtw-10\charscalex92 (1995), the normal ABR rea
dings recorded in some HIV-infected patients \line \up0 \expndtw-10\charscalex93
may be due in part to nonuniform procedures and techniques, which are \line \up
0 \expndtw-9\charscalex92 used in various clinics and studies. For instance, in
demyelinating disease \line \up0 \expndtw-10\charscalex96 processes, a change in
ABR click rates from slower to faster has been \line \up0 \expndtw-6\charscalex
100 shown to yield abnormal ABR ndings even when ABR responses \line \up0 \expnd
tw-9\charscalex95 might have appeared normal at lower click rates (Antonelli et
al., 1998). \line \up0 \expndtw-10\charscalex95 Neurophysiologic and neuropa
thologic studies \up0 \expndtw-10\charscalex95 (Anders, Guerra, \par\pard\qj
\li1286\ri962\sb1\sl-260\slmult0 \up0 \expndtw-9\charscalex96 Tomiyasu, Verity,
& V|nters, 1986; Grimaldi et al., 1993; Rostad, Sumi, \line \up0 \expndtw-10\ch
arscalex94 Shaw, Olson, & McDougall, 1987; Simpson & Bender, 1988) reveal that
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
90}{\bkmkend Pg90}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253
\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2856 \up0 \expndtw-10\charsc
alex97 \ul0\nosupersub\cf2\f3\fs22 70\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-257\slmult0 \par\pard\qj\li1551\ri694\sb75\sl-257\slmult0 \
up0 \expndtw-9\charscalex95 \ul0\nosupersub\cf2\f3\fs22 HIV infection induces ne
uropathologic alterations, especially subcortical \line \up0 \expndtw-10\charsca
lex97 demyelination (as in leukoencephalopathy) of portions of the medulla \lin
e \up0 \expndtw-10\charscalex96 pons and mid brain. Leukoencephalopathy is a com
mon manifestation \line \up0 \expndtw-6\charscalex100 in patients with full-b
lown AIDS. Demyelination in these areas \line \up0 \expndtw-9\charscalex96
(medulla, pons, and mid-brain) interferes with the temporal synch-\line
\up0 \expndtw-9\charscalex96 ronization of neural activity and transmission
of neural information \line \up0 \expndtw-8\charscalex100 through the cent
ral auditory pathways in HIV-infected individuals \line \up0 \expndtw-8\cha
rscalex100 and patients with AIDS (Rostad et al., 1987), resulting in signicantly
\line \up0 \expndtw-9\charscalex100 abnormal ABR ndings. \par\pard\ql \li3342\sb
0\sl-218\slmult0 \par\pard\ql\li3342\sb0\sl-218\slmult0 \par\pard\ql\li3342\sb12
0\sl-218\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 A\ul0
\nosupersub\cf31\f32\fs17 UDITORY\ul0\nosupersub\cf7\f8\fs24 P300 R\ul0\nosuper
sub\cf31\f32\fs17 ESPONSE \par\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\l
i1551\ri694\sb8\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupers
ub\cf2\f3\fs22 AIDS-related dementia is seen in up to 87% of patients
with \line \up0 \expndtw-8\charscalex100 AIDS (Price et al., 1988) as a result
of the involvement of subcortical \line \up0 \expndtw-10\charscalex97 and cortic
al levels of the CNS from opportunistic infections. The P300 \line \up0 \expndtw
-10\charscalex94 response develops approximately 300 ms after presentation of au
ditory \line \up0 \expndtw-9\charscalex94 stimulus and is generated at the
medial temporal lobe level, unlike \line \up0 \expndtw-9\charscalex100 ABR,
which develops approximately 10 ms after a presentation audi-\line \up0 \expnd
tw-9\charscalex100 tory stimulus. A P300 \up0 \expndtw-10\charscalex92 respon
se is thought to be generated at the \par\pard\qj \li1551\ri697\sb0\sl-26
0\slmult0 \up0 \expndtw-8\charscalex100 medial temporal lobe level and correspon
ds to various cognitive pro-\line \up0 \expndtw-10\charscalex95 cessing, which
requires short-term memory and the mental speed \line \up0 \expndtw-10\ch
arscalex94 essential in decision making \up0 \expndtw-10\charscalex96 (Ford,
Mohs, Pfeerbaum, & Kopell., \par\pard\qj \li1551\ri694\sb0\sl-260\slmult0 \up
0 \expndtw-10\charscalex96 1980). Studies involving immunocompromised HIV-positi
ve individuals \line \up0 \expndtw-9\charscalex93 and patients with AIDS reve
al abnormal increases in P300 response \line \up0 \expndtw-9\charscalex96 l
atencies, suggesting cortical involvement in this population (St. Claire, \line
\up0 \expndtw-10\charscalex95 Blackwood, & Christie, 1985). These ndings should n
ot be considered \line \up0 \expndtw-10\charscalex95 conclusive because there ha
ve been patients in whom the presence of \line \up0 \expndtw-9\charscalex93 deme
ntias such as those of the Alzheimer type has yielded normal \line \up
0 \expndtw-10\charscalex95 P300 responses (Syndulko et al., 1984). Audiologic e
valuation of HIV-\line \up0 \expndtw-8\charscalex100 infected individuals and pa
tients with AIDS should include a test bat-\line \up0 \expndtw-10\charscalex91 t
ery approach composed of comprehensive assessment components that \line \up0 \ex
pndtw-9\charscalex96 include, but are not limited to, pure tone and spe
ech audiometry, \line \up0 \expndtw-10\charscalex94 immittance measurements, ac
oustic reexes, OAE, and ABR audiome-\line \up0 \expndtw-9\charscalex100 try. The
focus of these test procedures should be on exploring altera-\line \up0 \expndtw
-7\charscalex100 tions of the external middle and inner ear as well as subcortic
al and \line \up0 \expndtw-9\charscalex98 cortical portions of the central audit
ory pathway due to the pathogenic \line \up0 \expndtw-10\charscalex98 actions of
HIV and AIDS-related complications.

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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
91}{\bkmkend Pg91}\par\pard\li4014\sb0\sl-241\slmult0\par\pard\li4014\sb0\sl-241
\slmult0\par\pard\li4014\sb201\sl-241\slmult0\fi0\tx7298 \up0 \expndtw-6\charsca
lex100 \ul0\nosupersub\cf5\f6\fs18 HIV/AIDS\tab \up0 \expndtw-8\charscalex100 \u
l0\nosupersub\cf2\f3\fs22 71\par\pard\qj \li1286\sb0\sl-262\slmult0 \par\pard\qj
\li1286\ri960\sb38\sl-262\slmult0\fi478 \up0 \expndtw-10\charscalex94 The preva
lence of both conductive and sensorineural hearing \line \up0 \expndtw-9\c
harscalex97 impairments in HIV-infected individuals and patients with AID
S is \line \up0 \expndtw-9\charscalex92 documented (Gherman et al., 1988; Kohan
et al., 1988; Real et al., 1987). \line \up0 \expndtw-9\charscalex94 The incide
nce of conductive hearing loss is reported to be less than that \line \up0 \expn
dtw-9\charscalex94 of sensorineural hearing impairment in this population (Sooy,
1987). The \line \up0 \expndtw-10\charscalex95 causes of sensorineural hearing
impairment are multifaceted and have \line \up0 \expndtw-9\charscalex95 been as
sociated with ototoxicity of the drugs used for prophylactic \line \up0
\expndtw-9\charscalex96 treatment of HIV-infected persons and AIDS-related
lesions of the \line \up0 \expndtw-9\charscalex91 cochlea and central auditor
y pathway of the CNS, such as acoustic cranial \line \up0 \expndtw-10\charscalex
91 nerve neuropathy (Soucek & Michaels, 1998). \par\pard\qj \li1286\ri960\sb0\sl
-262\slmult0\fi478 \up0 \expndtw-7\charscalex100 Conductive hearing impairment i
n HIV-positive individuals and \line \up0 \expndtw-9\charscalex96 patients with
AIDS is documented to be caused by otitis externa; \line \up0 \expndtw
-9\charscalex91 Kaposi\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f
3\fs22 s sarcoma; polyps in the external auditory meatus; serous, chronic, \line
\up0 \expndtw-9\charscalex95 or acute otitis media; and eustachian tube dysfunc
tion due to nasophar-\line \up0 \expndtw-9\charscalex88 yngeal neoplasms ( Gherm
an et al., 1988; Kohan et al., 1988). The causes of \line \up0 \expndtw-9\charsc
alex97 retrocochlear pathologic conditions in patients with AIDS are similar to
\line \up0 \expndtw-10\charscalex94 those of sensorineural hearing loss because
AIDS-related opportunistic \line \up0 \expndtw-9\charscalex95 infections and neo
plastic growths in the central auditory pathway, which \line \up0 \expndtw-9\cha
rscalex90 cause cochlear alterations, also produce peripheral vestibular anomali
es as \line \up0 \expndtw-10\charscalex94 well as lesions in the CNS. These lesi
ons often produce abnormal ABR \line \up0 \expndtw-10\charscalex86 and P300 resp
onses. \par\pard\ql \li3470\sb0\sl-276\slmult0 \par\pard\ql\li3470\sb0\sl-276\sl
mult0 \par\pard\ql\li3470\sb114\sl-276\slmult0 \up0 \expndtw0\charscalex105 \ul0
\nosupersub\cf7\f8\fs24 MANAGEMENT \par\pard\qj \li1286\ri959\sb257\sl-261\slmul
t0\fi478 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Aural rehabil
itation involves hearing aid evaluation and tting if \line \up0 \expndtw-10\chars
calex96 the degree of hearing loss or hearing handicap makes hearing aid use \li
ne \up0 \expndtw-9\charscalex94 appropriate. For patients with AIDS who present
retrocochlear disorders \line \up0 \expndtw-10\charscalex94 such as AIDS-related
dementia, Bankaitis and Keith (1995) suggested \line \up0 \expndtw-9\charscal
ex95 administering central auditory processing tests to assess functional
\line \up0 \expndtw-9\charscalex96 auditory processing skills and better p
lan and institute appropriate \line \up0 \expndtw-9\charscalex93 management
and rehabilitation strategies. For instance, HIV-infected \line \up0 \expnd
tw-7\charscalex100 individuals and patients with AIDS who recently experi
enced a \line \up0 \expndtw-10\charscalex96 signicant sudden sensorineural heari

ng loss, have an impaired CNS, \line \up0 \expndtw-9\charscalex93 and/or have po

or central auditory processing skills that aect speech and \line \up0 \expndtw-10
\charscalex97 language may benet from amplication as well as augmentative and \lin
e \up0 \expndtw-10\charscalex94 alternative communication.
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alex97 \ul0\nosupersub\cf2\f3\fs22 72\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\ql \li3842\sb0\sl-276\slmult0 \par\pard\ql\li3842\sb60\sl-276\slmult0 \up0 \e
xpndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 REFERENCES \par\pard\ql \li15
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93}{\bkmkend Pg93}\par\pard\li4014\sb0\sl-241\slmult0\par\pard\li4014\sb0\sl-241
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alex96 \ul0\nosupersub\cf2\f3\fs22 74\tab \up0 \expndtw-8\charscalex96 \ul0\nosu
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zheimer type and alcoholic Korsako syndrome. British Journal of Psychiatry, 147,\
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0\fi0\tx2924\tx6731\tx7108 \up0 \expndtw-8\charscalex91 Watson, D. W.\tab \up0
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tzsch, K. \tab \up0 \expndtw-6\charscalex100 (1992). Auditory brain stein r
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calex100 patients with immunotropic virus infection of dierent stages. Ear and He
aring, 13, \line \up0 \expndtw-8\charscalex82 55 ^57.
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\li2958\sb33\sl-276\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8
\fs24 SUGGESTED READINGS \par\pard\qj \li1286\sb0\sl-220\slmult0 \par\pard\qj\li
1286\ri994\sb51\sl-220\slmult0\tx1525 \up0 \expndtw-7\charscalex97 \ul0\nosupers
ub\cf5\f6\fs18 Bergstrom, L., & Thompson, P. L. (1984). Ototoxicity (pp. 119 ^13
4). In J. L. Northern, \line\tab \up0 \expndtw-8\charscalex91 (Ed.), Hearing dis
orders. Austin: Little, Brown. \par\pard\ql \li1286\sb11\sl-207\slmult0\tx5422 \
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H. K. \tab \up0 \expndtw-8\charscalex95 (1992). Histopathologic and \par\pard
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al changes in the temporal bones of HIV-infected human adults. \up0 \ex
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286\ri994\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-7\charscalex96 Coulman, C. U.,
Greene, I., & Archibald, R. W. R. (1987). Cutaneous pneumocystosis. \line\tab \
up0 \expndtw-8\charscalex85 Annals of Internal Medicine, 106, 396 ^398. \par\par
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Eng, R. H., Bishburg, E., Smith, S. M., & Kapila, R. (1986). Cryptococcal infec
tions in \line\tab \up0 \expndtw-7\charscalex93 patients with acquired immune
deciency syndrome. American Journal Medicine, \line \tab \up0 \expndtw-8\cha
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tw-8\charscalex90 Fallon, J.\tab \up0 \expndtw-7\charscalex92 (1990). Current
treatment for human immunodeciency virus infection.\par\pard\li1286\sb12\sl

-207\slmult0\fi239 \up0 \expndtw-8\charscalex91 Ear, Nose andThroat Journal, 69,

487^ 496.\par\pard\qj \li1286\ri994\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-7\c
harscalex96 Falloon, J., Eddy, J., W|ener, L., & Pizzo, P. A. (1989). Human immu
nodeciency virus \line\tab \up0 \expndtw-8\charscalex88 infection in children. Jo
urnal of Pediatrics, 144, 1^30. \par\pard\qj \li1286\ri995\sb0\sl-220\slmult0\tx
1525 \up0 \expndtw-7\charscalex98 Linstrom, C. J., & Gleich, L. L. (1993). Otosy
philis: Diagnosis and therapeutic update. \line\tab \up0 \expndtw-8\charscalex83
Journal of Otolaryngology, 22, 401^ 408. \par\pard\ql \li1286\sb10\sl-207\slmul
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20\slmult0\tx1525 \up0 \expndtw-7\charscalex94 Mahajan, S. L., Ikeda, Y., & Meye
rs, T. J. (1981). Acute acoustic nerve palsy associated \line\tab \up0 \expndtw8\charscalex91 with vincristine therapy. Cancer, 47, 2404 ^2406. \par\pard\li128
6\sb27\sl-207\slmult0\fi0\tx2634\tx6743 \up0 \expndtw-8\charscalex94 McArthur,
J. C.\tab \up0 \expndtw-8\charscalex94 (1987). Neurologic manifestations of
AIDS. Medicine\tab \up0 \expndtw-8\charscalex94 (Baltimore),\par\pard\li1286\s
b13\sl-207\slmult0\fi239 \up0 \expndtw-8\charscalex94 66,407^ 437.\par\pard\ql \
li1286\ri994\sb0\sl-220\slmult0\tx1525\tx1525 \up0 \expndtw-7\charscalex94 Park,
S., Wunderlich, H., Goldenberg, R. A., & Marshall, M. (1992). Pneumocystis cari
nii \line\tab \up0 \expndtw-7\charscalex93 infection in the middle ear. Archi
ves of Otolaryngology Head & Neck Surgery, 118, \line \tab \up0 \expndtw-8\cha
rscalex86 269 ^270. \par\pard\qj \li1286\ri993\sb0\sl-220\slmult0\tx1525 \up0 \e
xpndtw-7\charscalex94 Wasserman, L., & Haghighi, P. (1992). Otic and ophthalmic
pneumocystosis in acquired \line\tab \up0 \expndtw-7\charscalex87 immunodeciency
syndrome. Archives Pathology and Laboratory Medicine, 116, 500 ^503.
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w-8\charscalex100 References \par\pard\ql \li4310\sb0\sl-207\slmult0 \par\pard\q
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alex97 \ul0\nosupersub\cf2\f3\fs22 78\tab \up0 \expndtw-8\charscalex97 \ul0\nosu
persub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\pa
rd\qj \li1551\sb0\sl-257\slmult0 \par\pard\qj\li1551\ri694\sb75\sl-257\slmult0\f
i478 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 Dierent senses pro
vide us with dierent information. Touch oers \line \up0 \expndtw-10\charscalex93 u
s opportunities to experience our environment in a somewhat fragmen-\line \up0 \
expndtw-9\charscalex92 ted way, which are limited to objects that are close by a

nd not dangerous. \line \up0 \expndtw-8\charscalex100 Smell and taste provide

only limited information about the world \line \up0 \expndtw-9\charscalex
92 around us, generally require close proximity, and are not always a socially \
line \up0 \expndtw-10\charscalex96 acceptable way to explore an object or person
. V|sion and hearing are \line \up0 \expndtw-9\charscalex97 both\ul0\nosupersub\
cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 distance\ul0\nosupersub
\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 senses. They provide u
s with information about things \line \up0 \expndtw-8\charscalex100 and events t
hat exist away from our bodies. We rely most heavily on \line \up0 \expndtw-10\c
harscalex92 these two senses to learn about the world around us. \par\pard\qj \l
i1551\ri696\sb1\sl-260\slmult0\fi478 \up0 \expndtw-5\charscalex100 V|sual impai
rment has an impact on all aspects of early \line \up0 \expndtw-9\charsc
alex93 development, creates challenges with independent living, aects employ-\lin
e \up0 \expndtw-9\charscalex98 ment opportunities for adults, and increases
the risk of isolation for \line \up0 \expndtw-9\charscalex96 elderly persons. W
|th the absence of vision, access to information from \line \up0 \expndtw-9\char
scalex92 the other intact sensory systems, particularly hearing and touch, is cr
ucial. \par\pard\qj \li1551\ri696\sb0\sl-260\slmult0\fi478 \up0 \expndtw-5\chars
calex100 Children with visual impairment rely on hearing not only \line
\up0 \expndtw-10\charscalex93 for speech and language development and comm
unication but also \line \up0 \expndtw-9\charscalex95 for cognitive developm
ent and academic success. V|sually impaired \line \up0 \expndtw-9\charscalex
95 adults use hearing to access technology that helps them to function \l
ine \up0 \expndtw-9\charscalex93 independently at home and at work and to partic
ipate in leisure activities. \line \up0 \expndtw-9\charscalex95 V|sually impair
ed individuals of all ages use their hearing to orient \line \up0 \expn
dtw-10\charscalex96 themselves to people and things in their environment an
d to move \line \up0 \expndtw-10\charscalex87 about safely. \par\pard\qj \li155
1\ri696\sb3\sl-257\slmult0\fi478 \up0 \expndtw-9\charscalex91 Audiologists rare
ly receive specic training to assess individuals \line \up0 \expndtw-9\char
scalex95 with visual impairment, and because vision loss is a low-incid
ence \line \up0 \expndtw-9\charscalex97 disability, most audiologists have l
imited opportunity to see these \line \up0 \expndtw-7\charscalex100 individu
als in their practices. It can be intimidating to receive a \line \up0
\expndtw-9\charscalex92 request to assess someone who is visually impair
ed or, even worse, \line \up0 \expndtw-9\charscalex88 suspected of being\ul0\n
osupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 deafblind.\ul
0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 Nonetheles
s, early and accurate assessment \line \up0 \expndtw-4\charscalex100 of hearing
is critical to minimize the impact of the sensory impair-\line \up0 \expndtw-10\
charscalex97 ment(s) and to ensure appropriate management of vision and hearing
\line \up0 \expndtw-10\charscalex90 problems. \par\pard\qj \li1551\ri694\sb1\sl260\slmult0\fi478 \up0 \expndtw-10\charscalex96 The purpose of this chapter is t
o review the relationship between \up0 \expndtw-9\charscalex95 eye and ear disor
ders, provide relevant information about visual impair\up0 \expndtw-9\charscalex
93 ment and its potential impact on audiologic assessment, and present \u
p0 \expndtw-10\charscalex95 practical suggestions for how to modify audiologic t
esting to accommo\up0 \expndtw-9\charscalex97 date various visual problems. Inte
rpreting audiologic test results in the \up0 \expndtw-10\charscalex95 context of
a visual impairment and providing appropriate recommenda\up0 \expndtw-10\charsc
alex87 tions also are discussed.
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
99}{\bkmkend Pg99}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-241
\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7290 \up0 \expndtw-8\charsca
lex96 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expndtw
-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 79\par\pard\ql \li2234\sb0\sl-276\s
lmult0 \par\pard\ql\li2234\sb33\sl-276\slmult0 \up0 \expndtw0\charscalex102 \ul0
\nosupersub\cf7\f8\fs24 VISION LOSS: WHAT IT LOOKS LIKE \par\pard\qj \li1286\ri9
59\sb238\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91 \ul0\nosupersub\cf2\
f3\fs22 V|sion loss may be due to an eye disorder or brain damage, may be \line
\up0 \expndtw-9\charscalex94 present from birth or acquired later, and may range
from partial vision to \line \up0 \expndtw-9\charscalex95 total blindness. Indi
viduals with vision loss are a heterogeneous popula-\line \up0 \expndtw-9\charsc
alex97 tion presenting with diverse etiologies, various risk factors, and distin
ct \line \up0 \expndtw-9\charscalex90 clinical proles. Scott, Jan, and Freeman (1
995) report that in industrialized \line \up0 \expndtw-7\charscalex100 nations m
ost children with visual impairment are born with their eye \line \up0 \expndtw9\charscalex92 disorders, whereas about one quarter develop their vision loss la
ter in life. \line \up0 \expndtw-10\charscalex95 Severe visual impairment is unc
ommon in these countries, occurring in \line \up0 \expndtw-8\charscalex100 only
6 to 8 children of 10,000. In nonindustrialized nations, childhood \line \up0 \e
xpndtw-9\charscalex94 blindness is common but is usually acquired. Poor hygiene,
malnutrition, \line \up0 \expndtw-10\charscalex97 vitamin deciencies, and lack o
f immunizations predispose children in \line \up0 \expndtw-5\charscalex100 these
countries to infections. It is reported that more than 1 million \line \up0 \e
xpndtw-9\charscalex95 children develop blindness each year due to devastating ey
e infections. \line \up0 \expndtw-10\charscalex91 Most of these children die (Sc
ott et al., 1995). \par\pard\qj \li1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \exp
ndtw-9\charscalex100 The National Eye Institute (NEI) reported in 2004 that blin
dness \line \up0 \expndtw-9\charscalex100 or low vision aects 3.3 million America
ns 40 years or older. By 2020, \line \up0 \expndtw-9\charscalex95 this gure is pr
ojected to reach 5.5 million. The leading causes of visual \line \up0 \expndtw-7
\charscalex100 impairment and blindness in adults in the United States are diabe
tic \line \up0 \expndtw-10\charscalex93 retinopathy, age-related macular degener
ation, cataracts, and glaucoma \line \up0 \expndtw-10\charscalex94 (NEI, 2002).
\par\pard\ql \li3283\sb0\sl-218\slmult0 \par\pard\ql\li3283\sb0\sl-218\slmult0 \
par\pard\ql\li3283\sb79\sl-218\slmult0 \up0 \expndtw0\charscalex105 \ul0\nosuper
sub\cf7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17 OW THE\ul0\nosupersub\cf7\f8\fs24
E\ul0\nosupersub\cf31\f32\fs17 YE\ul0\nosupersub\cf7\f8\fs24 W\ul0\nosupersub
\cf31\f32\fs17 ORKS \par\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\
ri959\sb8\sl-260\slmult0\fi478 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2
\f3\fs22 The function of the eyes is to focus on an object of interest and \line
\up0 \expndtw-9\charscalex98 then transmit that information to the brain (Scott
et al., 1995). A trans-\line \up0 \expndtw-9\charscalex97 parent layer called t
he cornea covers the front of the eye. Light travels \line \up0 \expndtw-9\chars
calex94 through the cornea, passes through the pupil, and continues through the
\line \up0 \expndtw-9\charscalex91 lens. The lens focuses the rays of light on t
he retina at the back of the eye, \line \up0 \expndtw-10\charscalex96 which is c
omposed of millions of photoreceptor cells cones and rods. \line \up0 \expndtw
-9\charscalex93 Near the center of the retina is the macula, a small spot about
the size of \line \up0 \expndtw-9\charscalex96 a pea, which is responsible for p
rocessing the ne details of the image. \line \up0 \expndtw-8\charscalex100 Most c
ones are located in the macula, whereas most rods are in the \line \up0 \expndtw
-9\charscalex97 periphery of the retina. The macula needs bright light to work w
ell and \line \up0 \expndtw-8\charscalex100 allows us to see ne detail and color
. The remainder of the retina is \line \up0 \expndtw-8\charscalex100 responsible
for peripheral vision, perception of movement, and night
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53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2859 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 80\tab \up0 \expndtw-8\charscalex97 \ul0\no
supersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\
pard\qj \li1551\sb0\sl-255\slmult0 \par\pard\qj\li1551\ri694\sb79\sl-255\slmult0
\up0 \expndtw-9\charscalex94 \ul0\nosupersub\cf2\f3\fs22 vision. At the back of
the eye the nerve bers from the retinal cells come \up0 \expndtw-9\charscalex96
together to form the optic nerve. Messages from the retina travel along \up0 \ex
pndtw-9\charscalex97 the optic nerve to the brain. The visual centers, located i
n the occipital \up0 \expndtw-9\charscalex96 lobes, receive and then transmit th
is information to dierent parts of the \up0 \expndtw-10\charscalex89 brain for an
alysis (Fig. 4.1). \par\pard\qj \li1551\ri695\sb1\sl-260\slmult0\fi478 \up0 \exp
ndtw-10\charscalex89 To see normally, we need eyes that can perceive details up
close and \up0 \expndtw-9\charscalex93 at a distance, can distinguish between ob
jects with low contrast, are able \up0 \expndtw-7\charscalex100 to function in v
arious levels of ambient light, and move together in a \up0 \expndtw-9\charscale
x96 coordinated fashion. In addition, our brain must be capable of receiving \up
0 \expndtw-5\charscalex100 and analyzing the information from the eyes to tell u
s what we are \up0 \expndtw-9\charscalex97 seeing. It is an undisputed truth tha
t ultimately\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\
fs22 we see with our brains \up0 \expndtw-10\charscalex89 rather than our eyes.\
ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \par\pard\qj \li1551\ri695\sb2\sl-25
8\slmult0\fi478 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 Some c
omponents of vision, such as visual acuity and peripheral \line \up0 \expndtw-9\
charscalex91 visual elds, can be measured objectively under controlled circumstan
ces. \line \up0 \expndtw-9\charscalex92 Legal blindness, for example, is dened by
measurements of visual acuity \line \up0 \expndtw-9\charscalex94 and/or periphe
ral visual elds. V|sual function is what an individual does \line \up0 \expndtw-9
\charscalex93 with the vision he or she has and may give us a better idea of how
some-\line \up0 \expndtw-9\charscalex93 one manages in their daily life. Low vi
sion is more functionally dened as \line \up0 \expndtw-9\charscalex93 \ul0\nosupe
rsub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 a visual impairment
not correctable by standard glasses, contact lenses, \line \up0 \expndtw-7\char
scalex100 medicine or surgery that interferes with a person\ul0\nosupersub\cf11\
f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ability to perform \line \up0 \exp
ndtw-10\charscalex94 everyday activities\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8
217?\ul0\nosupersub\cf2\f3\fs22 (NEI, 2004). Two people may have the same visua
l \line \up0 \expndtw-8\charscalex100 acuity but may function dierently. In a you
ng child, visual acuity may \line \up0 \expndtw-7\charscalex100 stay the same bu
t visual function may improve with experience and \line \up0 \expndtw-10\charsca
lex96 intervention. \par\pard\qj \li1551\ri697\sb1\sl-260\slmult0\fi478 \up0 \ex
pndtw-10\charscalex95 It is critical that clinicians acquire an understanding of
the compo\up0 \expndtw-9\charscalex95 nents of functional vision and the role t
hey play in audiological testing in \up0 \expndtw-9\charscalex95 order to eective
ly structure the test setting, accurately interpret results, \up0 \expndtw-10\ch
arscalex90 and make appropriate recommendations (Table 4.1). \par\pard\ql \li339
3\sb0\sl-207\slmult0 \par\pard\ql\li3393\sb0\sl-207\slmult0 \par\pard\ql\li3393\
sb30\sl-207\slmult0 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 C\u
l0\nosupersub\cf31\f32\fs17 OMMON\ul0\nosupersub\cf7\f8\fs24 E\ul0\nosupersub\c
f31\f32\fs17 YE\ul0\nosupersub\cf7\f8\fs24 D\ul0\nosupersub\cf31\f32\fs17 ISORD

ERS \par\pard\ql \li4229\sb0\sl-253\slmult0 \par\pard\ql\li4229\sb22\sl-253\slmu

lt0 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 Cataracts \par\par
d\qj \li1551\ri697\sb122\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91 A c
ataract occurs when the normally transparent lens becomes \line \up0 \exp
ndtw-9\charscalex100 cloudy or opaque. Depending on the size and placeme
nt of the \line \up0 \expndtw-9\charscalex95 cataract, sight may be partia
lly or completely lost until the cataract \line \up0 \expndtw-6\charscalex1
00 is removed. Symptoms include cloudy or blurry vision, loss of \line
\up0 \expndtw-8\charscalex100 acuity, di\u8260?culty with glare, and poor night
vision. Age-related cataracts
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lex87 levels\par\pard\ql \li1952\sb0\sl-184\slmult0 \par\pard\ql \li1952\sb0\sl184\slmult0 \par\pard\ql \li1952\sb0\sl-184\slmult0 \par\pard\ql \li1952\sb0\sl184\slmult0 \par\pard\ql \li1952\sb0\sl-184\slmult0 \par\pard\ql \li1952\sb0\sl184\slmult0 \par\pard\ql \li1952\sb0\sl-184\slmult0 \par\pard\ql \li1952\sb43\sl
-184\slmult0\tx3288 \up0 \expndtw-7\charscalex95 Contrast\tab \up0 \expndtw-7\ch
arscalex88 Sharpness of contrast\par\pard\ql \li2111\sb16\sl-184\slmult0\tx3446
\up0 \expndtw-7\charscalex97 sensitivity\tab \up0 \expndtw-7\charscalex91 requir
ed to see things\par\pard\ql \li3451\sb14\sl-184\slmult0 \up0 \expndtw-7\charsca
lex89 clearly.\par\pard\column \ql \li5293\sb0\sl-184\slmult0 \par\pard\ql \li52
93\sb0\sl-184\slmult0 \par\pard\ql \li5293\sb0\sl-184\slmult0 \par\pard\ql \li52
93\sb0\sl-184\slmult0 \par\pard\ql \li20\sb120\sl-184\slmult0\tx1973 \up0 \expnd
tw-7\charscalex88 Eye muscles establish\tab \up0 \expndtw-7\charscalex92 Eye mov
ement disorders m\par\pard\ql \li179\sb15\sl-184\slmult0\tx2132 \up0 \expndtw-7\
charscalex95 and maintain\tab \up0 \expndtw-7\charscalex94 compromise ability to
scan\par\pard\ql \li179\sb16\sl-184\slmult0\tx2132 \up0 \expndtw-7\charscalex91
visual focus,\tab \up0 \expndtw-5\charscalex100 horizontally\par\pard\ql \li179
\sb14\sl-184\slmult0\tx2132 \up0 \expndtw-7\charscalex96 allowing person\tab \up
0 \expndtw-7\charscalex94 (i.e., oculomotor apraxia)\par\pard\ql \li179\sb16\sl184\slmult0\tx1973 \up0 \expndtw-7\charscalex90 to scan, fixate,\tab \up0 \expnd
tw-7\charscalex91 Strabismus compromises f\par\pard\ql \li179\sb15\sl-184\slmult
0\tx2132 \up0 \expndtw-7\charscalex90 locate, and track\tab \up0 \expndtw-7\char
scalex88 because direction of eyes\par\pard\ql \li179\sb16\sl-184\slmult0\tx2132
\up0 \expndtw-7\charscalex88 objects.\tab \up0 \expndtw-7\charscalex94 not coor
dinated.\par\pard\ql \li20\sb134\sl-184\slmult0\tx1973 \up0 \expndtw-6\charscale
x100 Daylight or medium\tab \up0 \expndtw-7\charscalex93 Varies according to eti
olog\par\pard\ql \li179\sb16\sl-184\slmult0\tx1973 \up0 \expndtw-4\charscalex100
artificial illumination\tab \up0 \expndtw-7\charscalex94 Those with retinal dis
orders\par\pard\ql \li179\sb14\sl-184\slmult0\tx2132 \up0 \expndtw-7\charscalex8
6 is adequate.\tab \up0 \expndtw-7\charscalex97 require lower lighting,\par\pard
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myo\par\pard\ql \li2127\sb15\sl-184\slmult0 \up0 \expndtw-7\charscalex91 or pres
byopia may need\par\pard\ql \li2127\sb15\sl-184\slmult0 \up0 \expndtw-7\charscal
ex95 increased illumination.\par\pard\ql \li5293\sb0\sl-184\slmult0 \par\pard\ql
\li5293\sb0\sl-184\slmult0 \par\pard\ql \li5293\sb0\sl-184\slmult0 \par\pard\ql
\li20\sb181\sl-184\slmult0\tx1973 \up0 \expndtw-6\charscalex100 Most things in
our\tab \up0 \expndtw-7\charscalex93 Inability to see subtle detail\par\pard\ql
\li179\sb16\sl-184\slmult0\tx2132 \up0 \expndtw-7\charscalex94 environment are\t
ab \up0 \expndtw-7\charscalex87 (e.g., features of a person\par\pard\ql \li179\s
b14\sl-184\slmult0\tx2132 \up0 \expndtw-7\charscalex94 low contrast.\tab \up0 \e
xpndtw-7\charscalex94 given the low contrast betw\par\pard\ql \li179\sb16\sl-184
\slmult0\tx2132 \up0 \expndtw-7\charscalex94 Persons with normal\tab \up0 \expnd
tw-7\charscalex88 each facial feature and\par\pard\ql \li179\sb15\sl-184\slmult0
\tx2132 \up0 \expndtw-7\charscalex94 vision do not need\tab \up0 \expndtw-5\char
scalex100 their similarity in color\par\pard\ql \li179\sb15\sl-184\slmult0 \up0
\expndtw-7\charscalex90 the contrast enhanced\par\pard\ql \li179\sb15\sl-184\slm
ult0 \up0 \expndtw-6\charscalex100 in order to identify\par\pard\ql \li179\sb16\
sl-184\slmult0 \up0 \expndtw-7\charscalex95 forms.
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5\f36\fs18 (\ul0\nosupersub\cf5\f6\fs18 continued\ul0\nosupersub\cf35\f36\fs18 )
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charscalex94 \ul0\nosupersub\cf3\f4\fs16 Component\tab \up0 \expndtw-7\charscale
x94 Definition\tab \up0 \expndtw-7\charscalex94 Normal\tab \up0 \expndtw-7\chars
calex94 Impairment\par\pard\li1953\sb87\sl-184\slmult0\fi0\tx3309\tx5386\tx7371
\up0 \expndtw-7\charscalex94 Cortical\tab \up0 \expndtw-7\charscalex94 Visual ce
nters located in\tab \up0 \expndtw-7\charscalex94 Able to perceive,\tab \up0 \ex
pndtw-7\charscalex94 Damage to the visual cen\par\pard\li1953\sb16\sl-184\slmult
0\fi158\tx3467\tx5546\tx7530 \up0 \expndtw-7\charscalex94 vision\tab \up0 \expnd
tw-7\charscalex94 the occipital lobes\tab \up0 \expndtw-7\charscalex94 interpret
, and create\tab \up0 \expndtw-7\charscalex94 pathways leading to t\par\pard\li3
467\sb14\sl-184\slmult0\fi0\tx5546\tx7371 \up0 \expndtw-7\charscalex94 receive i
nformation\tab \up0 \expndtw-7\charscalex94 meaning from the\tab \up0 \expndtw-7
\charscalex94 Cortical visual impairm\par\pard\li3467\sb16\sl-184\slmult0\fi0\tx
5546\tx7530 \up0 \expndtw-7\charscalex94 from the eye and\tab \up0 \expndtw-7\ch
arscalex94 information\tab \up0 \expndtw-7\charscalex94 be caused by infection\p
ar\pard\li3467\sb15\sl-184\slmult0\fi0\tx5546\tx7530 \up0 \expndtw-7\charscalex9
4 transmit it to various\tab \up0 \expndtw-7\charscalex94 transmitted by\tab \up
0 \expndtw-7\charscalex94 anoxia, toxins, tumor\par\pard\li3467\sb16\sl-184\slmu
lt0\fi0\tx5546\tx7530 \up0 \expndtw-7\charscalex94 parts of the brain\tab \up0 \
expndtw-7\charscalex94 the eye.\tab \up0 \expndtw-7\charscalex94 or various neur
ological\par\pard\li3467\sb14\sl-184\slmult0\fi0\tx7530 \up0 \expndtw-7\charscal
ex94 for analysis.\tab \up0 \expndtw-7\charscalex94 and it is frequently asso\pa
r\pard\qj \li7371\ri3900\sb0\sl-200\slmult0\fi158 \up0 \expndtw-6\charscalex100
with additional disabil \line \up0 \expndtw-7\charscalex93 Characterized by visu
al \line \up0 \expndtw-7\charscalex89 in-attentiveness; close \par\pard\ql \li75
30\ri3790\sb0\sl-200\slmult0 \up0 \expndtw-7\charscalex96 prolonged, compulsiv \
line \up0 \expndtw-7\charscalex96 light gazing; peripher \line \up0 \expndtw-7\c
harscalex91 field loss; variable visual \line \up0 \expndtw-5\charscalex100 and
difficulty interpr \line \up0 \expndtw-6\charscalex100 visual information. Con \
line \up0 \expndtw-7\charscalex91 eye problems may exi \line \up0 \expndtw-7\cha
rscalex97 particularly optic nerv \line \up0 \expndtw-7\charscalex91 Brain damag
e is com \line \up0 \expndtw-7\charscalex88 and often severe. \par\pard\qj \li19
53\ri3986\sb173\sl-200\slmult0 \up0 \expndtw-6\charscalex95 Adapted from: Gustin
, C. (1997). Audiological Assessment of Children withV|sual Impairment.The Heari
ngJou \up0 \expndtw-7\charscalex95 Lippincott W|lliams & W|lkins.)
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
105}{\bkmkend Pg105}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7292 \up0 \expndtw-8\chars
calex96 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 85\par\pard\qj \li1286\sb0\sl-260
\slmult0 \par\pard\qj\li1286\ri961\sb42\sl-260\slmult0 \up0 \expndtw-9\charscale
x95 are very common in elderly persons, most commonly after age 60 \lin
e \up0 \expndtw-9\charscalex91 years. Congenital cataracts are mostly hered
itary but occasionally are \line \up0 \expndtw-9\charscalex92 caused by a pre
natal infection, such as maternal rubella. Traumatic catar-\line \up0 \expndtw-9
\charscalex91 acts, resulting from an eye injury, can develop at any a
ge. Diabetes \line \up0 \expndtw-9\charscalex94 mellitus and certain medicat
ions also may cause the lens to cloud, \line \up0 \expndtw-10\charscalex8
7 creating cataracts. \par\pard\ql \li3904\sb0\sl-253\slmult0 \par\pard\ql\li390
4\sb133\sl-253\slmult0 \up0 \expndtw-4\charscalex100 Glaucoma \par\pard\qj \li12
86\ri959\sb122\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex92 Glaucoma is a
group of diseases in which increased pressure in the \up0 \expndtw-9\charscalex9
3 eye causes progressive damage to the retina and optic nerve. Peripheral \up0 \
expndtw-4\charscalex100 vision is aected rst, and if the condition is untreated,
then it can \up0 \expndtw-10\charscalex96 progress to complete blindness. Alt
hough commonly associated with \up0 \expndtw-8\charscalex100 aging, glaucoma can
aect individuals of any age. It also is common \up0 \expndtw-10\charscalex92 amo
ng people who have diabetes. Congenital glaucoma, which occurs in \up0 \expndtw10\charscalex93 children, is usually a genetic condition. \par\pard\ql \li3394\s
b0\sl-253\slmult0 \par\pard\ql\li3394\sb133\sl-253\slmult0 \up0 \expndtw-2\chars
calex100 Retinitis Pigmentosa \par\pard\qj \li1286\ri960\sb122\sl-260\slmult0\fi
478 \up0 \expndtw-9\charscalex89 Retinitis pigmentosa is a heterogeneous group o
f retinal disorders that \line \up0 \expndtw-10\charscalex94 can be associated w
ith a number of inherited eye^ear syndromes, most \line \up0 \expndtw-10\charsca
lex93 notably Usher\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\f
s22 s syndrome. The vision loss is caused by degeneration of \line \up0 \expndtw
-9\charscalex96 the retina, and it can aect children or adults. V|sual impairment
begins \line \up0 \expndtw-9\charscalex98 with a reduction in peripheral elds, w
hich progresses to tunnel vision \line \up0 \expndtw-9\charscalex93 and, in so
me cases, total blindness. In the early stages, individuals \line \up0 \
expndtw-2\charscalex100 with this problem may notice di\u8260?culty seeing in di
m lighting (night \line \up0 \expndtw-10\charscalex87 blindness). \par\pard\ql \

li3057\sb0\sl-253\slmult0 \par\pard\ql\li3057\sb133\sl-253\slmult0 \up0 \expndtw

0\charscalex100 Retinopathy of Prematurity \par\pard\ql \li1764\sb147\sl-253\slm
ult0\tx5970 \up0 \expndtw-8\charscalex100 Infants who are born with low bi
rthweight \tab \up0 \expndtw-10\charscalex86 (<1000 g) and are \par\pard\ql \l
i1286\sb7\sl-253\slmult0\tx3318\tx4050 \up0 \expndtw-10\charscalex92 delivered
prematurely \tab \up0 \expndtw-10\charscalex88 (26 ^28 \tab \up0 \expndtw-10\cha
rscalex92 weeks\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22
gestational age) are at risk for \par\pard\qj \li1286\ri959\sb2\sl-260\slm
ult0 \up0 \expndtw-9\charscalex92 developing retinopathy of prematurity. Classied
in ve stages depending \line \up0 \expndtw-8\charscalex100 on the extent of the
damage to the retina, vision loss can range from \line \up0 \expndtw-9\charscal
ex96 partial sight to total blindness. Early medical or surgical treatm
ent \line \up0 \expndtw-9\charscalex96 can now lessen or prevent vision lo
ss. Retinopathy of prematurity \line \up0 \expndtw-8\charscalex100 may be as
sociated with hearing loss in very low-birthweight infants \line \up0 \expndt
w-10\charscalex95 who survive.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
106}{\bkmkend Pg106}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2859 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 86\tab \up0 \expndtw-8\charscalex97 \ul0\no
supersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\
pard\ql \li3401\sb0\sl-253\slmult0 \par\pard\ql\li3401\sb82\sl-253\slmult0 \up0
\expndtw-1\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Cytomegalovirus Retinitis \
par\pard\qj \li1551\ri694\sb118\sl-264\slmult0\fi478 \up0 \expndtw-9\charscalex9
2 Cytomegalovirus retinitis is a potential complication of AIDS that \line
\up0 \expndtw-9\charscalex97 causes blindness; it occurs in the later stages of
the disease when the \line \up0 \expndtw-10\charscalex93 immune system becomes
more severely compromised. It may aect one \line \up0 \expndtw-10\charscalex91 ey
e rst but usually progresses to both. Symptoms may include scotomas \line \up0 \e
xpndtw-9\charscalex96 (focal peripheral eld loss), blurred vision, and a sudden
decrease in \line \up0 \expndtw-10\charscalex96 vision. \par\pard\ql \li3690\s
b0\sl-253\slmult0 \par\pard\ql\li3690\sb0\sl-253\slmult0 \par\pard\ql\li3690\sb6
0\sl-253\slmult0 \up0 \expndtw-2\charscalex100 Retinal Detachment \par\pard\qj \
li1551\ri697\sb139\sl-263\slmult0\fi478 \up0 \expndtw-10\charscalex94 Retinal de
tachment can occur at any age, but it is most often seen \line \up0 \expndtw-9\c
harscalex96 in middle-aged or older people. It can be spontaneous or c
aused \line \up0 \expndtw-6\charscalex100 by infection, by injury, and occasiona
lly by heredity. It also can be a \line \up0 \expndtw-9\charscalex96 complicatio
n of diabetes mellitus. Children and adults with severe \line \up0 \expn
dtw-9\charscalex93 myopia, such as that seen in Stickler syndrome, may b
e at risk for \line \up0 \expndtw-9\charscalex96 retinal detachment. Comple
te retinal detachment will result in total \line \up0 \expndtw-10\charscal
ex88 blindness. \par\pard\ql \li3634\sb0\sl-253\slmult0 \par\pard\ql\li3634\sb0\
sl-253\slmult0 \par\pard\ql\li3634\sb80\sl-253\slmult0 \up0 \expndtw-1\charscale
x100 Diabetic Retinopathy \par\pard\qj \li1551\ri697\sb117\sl-266\slmult0\fi478
\up0 \expndtw-10\charscalex91 Diabetic retinopathy is a leading cause of blindne
ss in adults; nearly \up0 \expndtw-7\charscalex100 half of all people with diabe
tes will eventually develop some degree \up0 \expndtw-10\charscalex100 of retino
pathy. Changes in the retinal blood vessels aect the macula, \up0 \expndtw-10\cha

rscalex92 causing blurred vision and loss of acuity. \par\pard\ql \li3598\sb0\sl

-253\slmult0 \par\pard\ql\li3598\sb0\sl-253\slmult0 \par\pard\ql\li3598\sb59\sl253\slmult0 \up0 \expndtw-4\charscalex100 Macular Degeneration \par\pard\qj \li1
551\ri697\sb117\sl-266\slmult0\fi478 \up0 \expndtw-10\charscalex89 Macular degen
eration is the most common cause of blindness in \line \up0 \expndtw-9\c
harscalex89 adults in western countries. Hereditary macular degeneration occa
sionally \line \up0 \expndtw-9\charscalex91 can aect children and adolescents. Th
e most common form is age-related \line \up0 \expndtw-10\charscalex91 macular d
egeneration, aecting people who are \up0 \expndtw-10\charscalex82 55 \up0 \ex
pndtw-10\charscalex91 years and older. \par\pard\qj \li1551\ri695\sb0\sl-266\s
lmult0 \up0 \expndtw-9\charscalex100 The severity of the disease can vary, and v
ision loss may range from \line \up0 \expndtw-1\charscalex100 mildly distorted o
r wavy vision, to di\u8260?culty reading or performing \line \up0 \expndtw-9\cha
rscalex94 tasks that require the ability to see ne detail, to complete loss of ce
ntral \line \up0 \expndtw-10\charscalex94 vision.
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
107}{\bkmkend Pg107}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7290 \up0 \expndtw-8\chars
calex96 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 87\par\pard\ql \li3377\sb0\sl-253
\slmult0 \par\pard\ql\li3377\sb55\sl-253\slmult0 \up0 \expndtw0\charscalex100 Op
tic Nerve Atrophy \par\pard\qj \li1286\ri960\sb118\sl-264\slmult0\fi478 \up0 \ex
pndtw-10\charscalex91 Optic nerve atrophy can result from various insults to the
optic nerve \line \up0 \expndtw-9\charscalex94 at any age after birth.When the
damage to the optic nerve occurs before \line \up0 \expndtw-7\charscalex100 the
end of pregnancy, the optic nerve heads may be small and mal-\line \up0 \expndtw
-9\charscalex92 formed, resulting in optic nerve hypoplasia. Because of advances
in medi-\line \up0 \expndtw-9\charscalex100 cine, optic nerve atrophy is much l
ess common than it was just a few \line \up0 \expndtw-10\charscalex83 decades ag
o. \par\pard\ql \li3602\sb0\sl-253\slmult0 \par\pard\ql\li3602\sb153\sl-253\slmu
lt0 \up0 \expndtw-2\charscalex100 Corneal Opacity \par\pard\qj \li1286\ri960\sb1
42\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 Corneal opacity is caused
by malnutrition and infections. It is the \up0 \expndtw-4\charscalex100 most com
mon type of blindness in the world, but it is seen almost \up0 \expndtw-10\chars
calex92 exclusively in underdeveloped countries. \par\pard\ql \li3091\sb0\sl-253
\slmult0 \par\pard\ql\li3091\sb153\sl-253\slmult0 \up0 \expndtw-1\charscalex100
Cortical V|sual Impairment \par\pard\qj \li1286\ri959\sb138\sl-264\slmult0\fi478
\up0 \expndtw-10\charscalex95 Cortical visual impairment occurs when certain vi
sual areas of the \line \up0 \expndtw-9\charscalex93 brain have been aected by la
ck of oxygen, developmental abnormalities, \line \up0 \expndtw-9\charscalex96 in
fections, or other diseases or injury. The eyes most often are normal, \line \up
0 \expndtw-9\charscalex97 but acuity still may be severely aected. Variable visua
l function, visual \line \up0 \expndtw-7\charscalex100 inattention, light gazing
, sensitivity to light, peripheral eld loss, and \line \up0 \expndtw-10\charscal
ex92 various visual perceptual problems are among the symptoms. \par\pard\ql \li
2525\sb0\sl-280\slmult0 \par\pard\ql\li2525\sb0\sl-280\slmult0 \par\pard\ql\li25
25\ri2244\sb163\sl-280\slmult0\tx3033 \up0 \expndtw0\charscalex102 \ul0\nosupers
ub\cf7\f8\fs24 RELATIONSHIP BETWEEN EYE \line\tab \up0 \expndtw0\charscalex103 A
ND EAR DISORDERS \par\pard\qj \li1286\ri959\sb253\sl-265\slmult0\fi478 \up0 \exp

ndtw-9\charscalex93 \ul0\nosupersub\cf2\f3\fs22 Embryologically, the eye (opt

ic placode) and ear (otic capsule) \line \up0 \expndtw-10\charscalex95 deve
lop simultaneously from the same type of tissue (neuroectoderm). \line \up0 \exp
ndtw-10\charscalex95 Any in-utero insult that causes a developmental problem in
one system \line \up0 \expndtw-10\charscalex96 may aect the other (Gustin & Schoe
m, 1999). Prenatal causes of dual \line \up0 \expndtw-10\charscalex94 sensory (h
earing and visual) impairment can include maternal drug and \line \up0 \expndtw9\charscalex96 alcohol abuse; low birthweight related to prematurity and i
nfectious \line \up0 \expndtw-9\charscalex93 agents, such as cytomegalovirus and
herpesvirus; and infections such as \line \up0 \expndtw-10\charscalex94 toxopla
smosis, acquired immunodeciency syndrome (AIDS), maternal \line \up0 \expndtw-10\
charscalex93 rubella, and syphilis.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
108}{\bkmkend Pg108}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2860 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 88\tab \up0 \expndtw-8\charscalex97 \ul0\no
supersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\
pard\qj \li1551\sb0\sl-258\slmult0 \par\pard\qj\li1551\ri694\sb73\sl-258\slmult0
\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 Most inherited
hearing loss occurs independently of any other dis-\line \up0 \expndtw-9\charsca
lex91 ease process or abnormalities ( Jacobsen, 1995). However, in a number of \
line \up0 \expndtw-10\charscalex92 genetic syndromes both hearing and visual imp
airments are seen. Gustin \line \up0 \expndtw-10\charscalex95 and Schoem (1999)
reported that, of the more than 200 known syndro-\line \up0 \expndtw-9\charscale
x91 mic hereditary hearing disorders, more than 40 (20%) have associated eye \li
ne \up0 \expndtw-10\charscalex95 problems. Although recent improvements in
prenatal and neonatal \line \up0 \expndtw-9\charscalex100 care have resulted i
n a decline in the sporadic (nonhereditary) forms \line \up0 \expndtw-9\charsca
lex95 of dual-sensory disorders, an increase in the hereditary types of ey
e \line \up0 \expndtw-9\charscalex96 and ear disorders has been seen. Ther
efore the Joint Committee \line \up0 \expndtw-10\charscalex95 on Infant Heari
ng in their Year 2000 Position Statement recommended \line \up0 \expndtw-10\char
scalex93 that \up0 \expndtw-9\charscalex95 \ul0\nosupersub\cf11\f12\fs22 \u8216?
\u8216?\ul0\nosupersub\cf2\f3\fs22 . . .every infant with hearing loss sho
uld receive an ophthal-\line \up0 \expndtw-9\charscalex95 mologic evaluation
at regular intervals to rule out late-onset vision \line \up0 \expndtw10\charscalex84 disorders\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupe
rsub\cf2\f3\fs22 (p. 11). \par\pard\qj \li1551\ri695\sb1\sl-260\slmult0\fi478 \
up0 \expndtw-10\charscalex96 Acquired hearing or visual impairments may result f
rom infection \line \up0 \expndtw-9\charscalex94 (e.g., encephalitis, cytomegalo
virus, meningitis, AIDS), asphyxia, stroke, \line \up0 \expndtw-9\charscalex95 o
r traumatic head injury. Aging also aects both the eye and ear; almost \line \up0
\expndtw-9\charscalex91 every elderly person experiences some degree of presbyc
usis (age-related \line \up0 \expndtw-10\charscalex91 hearing loss), as well
as age-related changes in vision \up0 \expndtw-10\charscalex91 (presbyopia)
\par\pard\ql \li1551\sb6\sl-253\slmult0 \up0 \expndtw-10\charscalex86 (Table 4.
2). \par\pard\ql \li2293\sb0\sl-276\slmult0 \par\pard\ql\li2293\sb232\sl-276\slm
ult0 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 IMPACT OF VISION O
N DEVELOPMENT \par\pard\qj \li1551\ri695\sb238\sl-260\slmult0\fi478 \up0 \expndt

w-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 There is general agreement tha

t vision is probably the most \up0 \expndtw-7\charscalex100 important modal
ity for knowledge acquisition (Lechelt & Hall, 2000). \up0 \expndtw-10\charscale
x91 Cognitive, speech and language, motor, and socioemotional development \up0 \
expndtw-10\charscalex92 are all aected by vision. \par\pard\qj \li1551\ri695\sb0\
sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 V|sion provides immediate
and simultaneous access to infor-\line \up0 \expndtw-4\charscalex100 mation
about our environment. A child watching a ball roll toward \line \up0 \expndtw-9
\charscalex95 him or her sees the color, shape, and size of the ball
as well as \line \up0 \expndtw-7\charscalex100 how it moves. Using only heari
ng and touch, a blind child accesses \line \up0 \expndtw-4\charscalex100 informa
tion about the properties and function of a ball in a limited \line \up0 \expndt
w-7\charscalex100 and fragmented way. V|sion is also a strong motivator
in motor \line \up0 \expndtw-7\charscalex100 development. The ability to se
e encourages children to lift their \line \up0 \expndtw-9\charscalex97 head
s, to reach for objects, and to begin to move about in their \line \
up0 \expndtw-10\charscalex97 environment. \par\pard\qj \li1551\ri697\sb0\sl-260\
slmult0\fi478 \up0 \expndtw-10\charscalex91 A child\ul0\nosupersub\cf11\f12\fs2
2 \u8217?\ul0\nosupersub\cf2\f3\fs22 s speech and language development reect
s his or her \line \up0 \expndtw-10\charscalex92 experience of the world. Thi
s diers for sighted and blind children.
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\landscape\paperw13020\paperh8700\pard\sb0\sl-240{\bk
mkstart Pg109}{\bkmkend Pg109}\par\pard\ql \li6537\sb0\sl-207\slmult0 \par\pard\
ql\li6537\sb0\sl-207\slmult0 \par\pard\ql\li6537\sb0\sl-207\slmult0 \par\pard\ql
\li6537\sb0\sl-207\slmult0 \par\pard\ql\li6537\sb0\sl-207\slmult0 \par\pard\ql\l
i6537\sb134\sl-207\slmult0 \up0 \expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\f
s18 Table 4.2 \par\pard\ql \li4659\sb73\sl-207\slmult0 \up0 \expndtw-1\charscale
x100 Etiologies of Combined Hearing and Visual Impairm \par\pard\li1953\sb133\sl
-184\slmult0\fi0\tx7412 \up0 \expndtw-6\charscalex100 \ul0\nosupersub\cf3\f4\fs1
6 Etiology\tab \up0 \expndtw-6\charscalex100 Vision\par\pard\li1953\sb87\sl-184\
slmult0\fi0 \up0 \expndtw-6\charscalex100 Syndromes/associations/sequences\par\p
ard\sect\sectd\sbknone\cols2\colno1\colw5891\colsr160\colno2\colw6829\colsr160\q
l \li1953\sb16\sl-184\slmult0 \up0 \expndtw-7\charscalex96 Alport syndrome (Type
I, II, and VI)\par\pard\ql \li1953\sb16\sl-184\slmult0 \up0 \expndtw-7\charscal
ex97 Alstrom syndrome\par\pard\ql \li1953\sb14\sl-184\slmult0 \up0 \expndtw-7\ch
arscalex91 Cerebral palsy\par\pard\ql \li1953\sb16\sl-184\slmult0 \up0 \expndtw7\charscalex95 CHARGE association\par\pard\ql \li1953\sb15\sl-184\slmult0 \up0 \
expndtw-7\charscalex92 Down\ul0\nosupersub\cf4\f5\fs16 \u8217?\ul0\nosupersub\cf
3\f4\fs16 s syndrome (Trisomy 21)\par\pard\qj \li1953\ri721\sb5\sl-198\slmult0 \
up0 \expndtw-7\charscalex92 Duane syndrome (cervico-oculoacoustic dysplasia) \up
0 \expndtw-7\charscalex88 Friederich\ul0\nosupersub\cf4\f5\fs16 \u8217?\ul0\nosu
persub\cf3\f4\fs16 s ataxia\par\pard\ql \li1953\sb14\sl-184\slmult0 \up0 \expndt
w-7\charscalex94 Marshall syndrome\par\pard\ql \li1953\sb15\sl-184\slmult0 \up0
\expndtw-7\charscalex96 Neurofibromatosis\par\pard\qj \li1953\ri375\sb5\sl-198\s
lmult0 \up0 \expndtw-7\charscalex92 Norrie syndrome (oculoacoustico cerebral deg
eneration) \up0 \expndtw-7\charscalex94 Refsum syndrome\par\pard\ql \li1953\sb14
\sl-184\slmult0 \up0 \expndtw-7\charscalex91 Stickler\ul0\nosupersub\cf4\f5\fs16
\u8217?\ul0\nosupersub\cf3\f4\fs16 s syndrome\par\pard\ql \li1953\sb15\sl-184\s
lmult0 \up0 \expndtw-7\charscalex95 Usher syndrome (Types I^III)\par\pard\ql \li

1953\sb16\sl-184\slmult0 \up0 \expndtw-7\charscalex96 Wolfram syndrome\par\pard\

ql \li1953\sb135\sl-184\slmult0 \up0 \expndtw-3\charscalex100 Prenatal\par\pard\
ql \li1953\sb14\sl-184\slmult0 \up0 \expndtw-7\charscalex93 Infections: congenit
al rubella, toxoplasmosis,\par\pard\ql \li2111\sb16\sl-184\slmult0 \up0 \expndtw
-7\charscalex94 cytomegalovirus (CMV), syphilis, herpes\par\pard\ql \li1953\sb15
\sl-184\slmult0 \up0 \expndtw-7\charscalex93 Fetal Alcohol Syndrome (FAS)\par\pa
rd\ql \li1953\sb16\sl-184\slmult0 \up0 \expndtw-7\charscalex92 Maternal drug abu
se\par\pard\ql \li1953\sb14\sl-184\slmult0 \up0 \expndtw-6\charscalex100 Anoxia\
par\pard\ql \li1953\sb16\sl-184\slmult0 \up0 \expndtw-6\charscalex100 Prematurit
y\par\pard\column \ql \li20\sb16\sl-184\slmult0 \up0 \expndtw-7\charscalex91 Myo
pia/cataracts\par\pard\ql \li20\sb16\sl-184\slmult0 \up0 \expndtw-7\charscalex96
Retinitis pigmentosa\par\pard\ql \li20\sb14\sl-184\slmult0 \up0 \expndtw-7\char
scalex95 Optic nerve atrophy/hemianopia\par\pard\ql \li20\sb16\sl-184\slmult0 \u
p0 \expndtw-6\charscalex100 Colomboma\par\pard\ql \li20\sb15\sl-184\slmult0 \up0
\expndtw-5\charscalex100 Myopia\par\pard\ql \li20\sb16\sl-184\slmult0 \up0 \exp
ndtw-7\charscalex93 Eye movement disorder\par\pard\ql \li20\sb14\sl-184\slmult0
\up0 \expndtw-7\charscalex96 Optic nerve atrophy\par\pard\ql \li20\sb16\sl-184\s
lmult0 \up0 \expndtw-7\charscalex90 Myopia/cataracts/strabismus\par\pard\ql \li2
0\ri4237\sb4\sl-198\slmult0\fi0 \up0 \expndtw-7\charscalex94 Optic nerve atrophy
/optic nerve gliomas \up0 \expndtw-7\charscalex89 Cataract/progressive loss to b
lindness \up0 \expndtw-7\charscalex96 Retinitis pigmentosa\par\pard\qj \li20\ri4
418\sb2\sl-199\slmult0 \up0 \expndtw-7\charscalex95 Myopia leading to retinal de
tachment \up0 \expndtw-7\charscalex96 Retinitis pigmentosa\par\pard\ql \li20\sb1
4\sl-184\slmult0 \up0 \expndtw-7\charscalex94 Optic nerve hypoplasia\par\pard\qj
\li6051\sb0\sl-199\slmult0 \par\pard\qj \li20\ri3910\sb122\sl-199\slmult0\tx189
\up0 \expndtw-7\charscalex91 Optic nerve damage/retinal disorders/cataracts \li
ne\tab \up0 \expndtw-7\charscalex96 cortical visual impairment\par\pard\qj \li20
\ri3835\sb0\sl-199\slmult0\fi0 \up0 \expndtw-7\charscalex94 Optic nerve damage/c
ortical visual impairme \up0 \expndtw-7\charscalex94 Optic nerve damage/cortical
visual impairme \up0 \expndtw-7\charscalex95 Optic nerve hypoplasia/cortical vi
sual impairm \up0 \expndtw-7\charscalex100 Retinopathy of prematurity
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\landscape\paperw13020\paperh8700\pard\sb0\sl-240{\bk
mkstart Pg110}{\bkmkend Pg110}\par\pard\qj \li6520\sb0\sl-280\slmult0 \par\pard\
qj\li6520\sb0\sl-280\slmult0 \par\pard\qj\li6520\sb0\sl-280\slmult0 \par\pard\qj
\li6520\sb0\sl-280\slmult0 \par\pard\qj\li6520\sb0\sl-280\slmult0 \par\pard\qj\l
i6520\sb0\sl-280\slmult0 \par\pard\qj\li6520\sb0\sl-280\slmult0 \par\pard\qj\li6
520\sb0\sl-280\slmult0 \par\pard\qj\li6520\sb0\sl-280\slmult0 \par\pard\qj\li652
0\sb0\sl-280\slmult0 \par\pard\qj\li6520\ri5586\sb129\sl-280\slmult0\fi17 \up0 \
expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 Table 4.2 \line \up0 \expndtw
-8\charscalex83 \ul0\nosupersub\cf35\f36\fs18 (\ul0\nosupersub\cf5\f6\fs18 conti
nued\ul0\nosupersub\cf35\f36\fs18 ) \par\pard\li1953\sb126\sl-184\slmult0\fi0\tx
7293 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf3\f4\fs16 Etiology\tab \up0
\expndtw-3\charscalex100 Vision\par\pard\li1953\sb87\sl-184\slmult0\fi0 \up0 \e
xpndtw-3\charscalex100 Acquired\par\pard\sect\sectd\sbknone\cols2\colno1\colw573
8\colsr160\colno2\colw6982\colsr160\ql \li1953\sb15\sl-184\slmult0 \up0 \expndtw
-7\charscalex95 Infections: Meningitis/encephalitis/cytomegalovirus,\par\pard\qj
\li1953\ri657\sb5\sl-198\slmult0\fi158 \up0 \expndtw-7\charscalex96 acquired im
munodeficiency syndrome (AIDS) \up0 \expndtw-7\charscalex96 Asphyxia\par\pard\ql
\li1953\sb14\sl-184\slmult0 \up0 \expndtw-7\charscalex92 Trauma\par\pard\ql \li
1953\sb0\sl-184\slmult0 \par\pard\ql \li1953\sb30\sl-184\slmult0 \up0 \expndtw-7
\charscalex93 Stroke\par\pard\ql \li1953\sb16\sl-184\slmult0 \up0 \expndtw-3\cha
rscalex100 Aging\par\pard\column \ql \li20\sb15\sl-184\slmult0 \up0 \expndtw-7\c
harscalex96 Optic nerve atrophy/cortical visual impairment\par\pard\qj \li5898\s
b0\sl-199\slmult0 \par\pard\qj \li20\ri3970\sb3\sl-199\slmult0\tx190 \up0 \expnd
tw-7\charscalex94 Optic nerve damage/cortical visual impairment \up0 \expndtw-7\
charscalex95 Optic nerve hypoplasia/cortical visual-impairm \line\tab \up0 \expn
dtw-7\charscalex91 cataracts/retinal bleeding/corneal scarring\par\pard\qj \li20
\ri3927\sb0\sl-199\slmult0\fi0 \up0 \expndtw-7\charscalex94 Optic nerve hypoplas
ia/cortical visual impairme \up0 \expndtw-7\charscalex92 Macular degeneration/pr
esbyopia
{\shp {\*\shpinst\shpleft1953\shptop3786\shpright11798\shpbottom3807\shpfhdr0\sh
pbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz6\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 9845}}{\sp{\sn geoBottom}{\sv 21}}
{\sp{\sn pVerticies}{\sv 8;4;(9845,0);(9845,21);(0,21);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1953\shptop5809\shpright11798\shpbottom5830\shpfhdr0\sh
pbxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 9845}}{\sp{\sn geoBottom}{\sv 21}}
{\sp{\sn pVerticies}{\sv 8;4;(9845,0);(9845,21);(0,21);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp {\*\shpinst\shpleft1953\shptop4065\shpright9764\shpbottom4085\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz10\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 7811}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(7811,20);(7811,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
111}{\bkmkend Pg111}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7292 \up0 \expndtw-8\chars
calex96 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 91\par\pard\qj \li1286\sb0\sl-260
\slmult0 \par\pard\qj\li1286\ri960\sb42\sl-260\slmult0 \up0 \expndtw-8\charscale
x100 A sighted child\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\
fs22 s rst words usually include names of things that are \line \up0 \expndtw-9\
charscalex94 experienced visually (e.g.,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u
8216?\ul0\nosupersub\cf2\f3\fs22 ball\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\n
osupersub\cf2\f3\fs22 ,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosuper
sub\cf2\f3\fs22 truck\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3
\fs22 ,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22
doggie\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 ).
The early vocabulary \line \up0 \expndtw-9\charscalex97 of visually impaired
children often includes names of objects that \line \up0 \expndtw-10\char
scalex94 have a distinctive feel \up0 \expndtw-10\charscalex85 (e.g., \up0 \e
xpndtw-10\charscalex92 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupers
ub\cf2\f3\fs22 water\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\
cf2\f3\fs22 ), sound \up0 \expndtw-10\charscalex85 (e.g., \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22
bell\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 ),
or smell \par\pard\qj \li1286\ri959\sb0\sl-263\slmult0 \up0 \expndtw-9\charsca
lex97 (e.g.,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\
fs22 French fries\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2
\f3\fs22 ). As visually impaired children become older, their \line \up0 \expndt
w-9\charscalex97 vocabulary may reect more restricted denitions or an impe
rfect \line \up0 \expndtw-10\charscalex96 understanding of the properties asso
ciated with words. For example, \line \up0 \expndtw-9\charscalex98 when one o
f our patients who had been totally blind since birth \line \up0 \expnd
tw-10\charscalex96 turned \up0 \expndtw-10\charscalex88 8 \up0 \expndtw-10\chars
calex95 years old, she began insisting that she could now see. \line \u
p0 \expndtw-10\charscalex94 When asked for an example of what she could see, she
said,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 I
can see \line \up0 \expndtw-10\charscalex92 lunchtime.\ul0\nosupersub\cf11\f12\
fs22 \u8217?\u8217? \par\pard\qj \li1286\ri961\sb0\sl-262\slmult0\fi478 \up0 \ex
pndtw-9\charscalex93 \ul0\nosupersub\cf2\f3\fs22 V|sion also plays a pivotal rol
e in the development of auditory skills. \line \up0 \expndtw-10\charscalex95 Sig
hted children learn to recognize sounds by hearing a sound, looking \line \up0 \
expndtw-6\charscalex100 to see what made the sound, and putting that information
together. \line \up0 \expndtw-9\charscalex100 Children with visual impairmen
t often need to experience sound \line \up0 \expndtw-7\charscalex100 (i.e.,
hold their hand under running water), have it labeled (\ul0\nosupersub\cf11\f1
2\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 water\ul0\nosupersub\cf11\f12\f
s22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 ), \line \up0 \expndtw-9\charscale
x98 and then interpreted (\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosup
ersub\cf2\f3\fs22 It\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\
fs22 s bath time\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\
f3\fs22 ). A sighted child learns to turn to \line \up0 \expndtw-5\charscalex100
a sound with the expectation of seeing something. A visually \line \up

0 \expndtw-8\charscalex100 impaired child may stop and listen, turn his or her e
ar in the direction \line \up0 \expndtw-9\charscalex96 of a sound, or reach for
the sound rather than turning to face the sound \line \up0 \expndtw-10\charscale
x84 source. \par\pard\qj \li1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-9\
charscalex100 The impact of vision loss on an individual depends on a number \up
0 \expndtw-10\charscalex92 of factors: \par\pard\ql \li2093\ri2556\sb116\sl-260\
slmult0 \up0 \expndtw-10\charscalex92 What are the type and degree of vision los
s? \line \up0 \expndtw-10\charscalex92 Is the vision loss congenital or acquired
? \line \up0 \expndtw-10\charscalex91 When was the vision loss diagnosed? \line
\up0 \expndtw-10\charscalex92 What intervention is provided and when? \par\pard\
qj \li2093\ri962\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex94 What addition
al physical, cognitive, and/or sensory impair\up0 \expndtw-10\charscalex86
ments are present? \par\pard\ql \li1991\sb0\sl-280\slmult0 \par\pard\ql\li1991\r
i1710\sb264\sl-280\slmult0\tx2919 \up0 \expndtw0\charscalex103 \ul0\nosupersub\c
f7\f8\fs24 ROLE OF HEARING FOR THE VISUALLY \line\tab \up0 \expndtw0\charscalex1
04 IMPAIRED POPULATION \par\pard\qj \li1286\ri959\sb257\sl-260\slmult0\fi478 \up
0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 Human beings hear at seve
ral dierent levels. The Primitive level \line \up0 \expndtw-9\charscalex95 is th
e most unconscious level of auditory function. Hearing at this \line \u
p0 \expndtw-10\charscalex95 level carries the auditory background \up0 \expn
dtw-10\charscalex95 (sounds that identify the
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz107\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
112}{\bkmkend Pg112}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2857 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 92\tab \up0 \expndtw-8\charscalex97 \ul0\no
supersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\
pard\qj \li1551\sb0\sl-258\slmult0 \par\pard\qj\li1551\ri696\sb73\sl-258\slmult0
\up0 \expndtw-9\charscalex94 \ul0\nosupersub\cf2\f3\fs22 environment) and the b
iologic sounds of our bodies (breathing, swallow-\line \up0 \expndtw-8\charscale
x100 ing, chewing, heartbeat, and pulse). It allows us to feel connected to \lin
e \up0 \expndtw-9\charscalex100 our environment and to our own bodies. At
the Signal-Warning/ \line \up0 \expndtw-9\charscalex100 Passive Learning leve
l, hearing functions to monitor the world around \line \up0 \expndtw-9\charscale
x96 us and alert us to danger. It allows us to passively absorb info
r-\line \up0 \expndtw-10\charscalex96 mation \up0 \expndtw-5\charscalex100 (incl
uding tangential information that is not specically \line \up0 \expndtw-8\c
harscalex100 directed to us) and social cues. The most sophisticated le
vel of \line \up0 \expndtw-9\charscalex91 hearing is the Symbolic level, wh
ich encompasses active listening and \line \up0 \expndtw-9\charscalex96 is r
esponsible for the development of speech and language skills \line \up0
\expndtw-6\charscalex100 and spoken communication and for active learning.
Individuals \line \up0 \expndtw-9\charscalex98 with visual impairment rely
more heavily on all levels of hearing \line \up0 \expndtw-10\charscalex98
than those with normal vision. \par\pard\qj \li1551\ri697\sb1\sl-260\slmult0\fi
478 \up0 \expndtw-10\charscalex95 Hearing plays a pivotal role in the developmen
t of orientation and \up0 \expndtw-7\charscalex100 mobility skills. Among the au
ditory skills described by Hill (1986) as \up0 \expndtw-10\charscalex95 necessa
ry for orientation and mobility are the following: \par\pard\ql \li2358\sb126\sl
-253\slmult0 \up0 \expndtw-10\charscalex93 Sound localization \par\pard\ql \li23

58\ri2243\sb2\sl-260\slmult0 \up0 \expndtw-10\charscalex95 Sound identication \li

ne \up0 \expndtw-10\charscalex96 Sound discrimination \line \up0 \expndtw-10\cha
rscalex94 Echo location \par\pard\ql \li2358\sb6\sl-253\slmult0 \up0 \expndtw-10
\charscalex91 Use of sound shadows \par\pard\qj \li1551\ri695\sb145\sl-256\slmul
t0\fi478 \up0 \expndtw-6\charscalex100 Although technology that provides auditor
y and tactile cues to \line \up0 \expndtw-9\charscalex95 assist with independent
travel exists, most visually impaired people rely \line \up0 \expndtw-9\charsca
lex96 on echo location. This involves the ability to use sound reection,
\line \up0 \expndtw-9\charscalex96 changes in air pressure, the absence of soun
d, and the identication of \line \up0 \expndtw-10\charscalex97 auditory landmarks
or changes in auditory background for orientation. \line \up0 \expndtw-10\chars
calex95 For example, a blind adult needing assistance while shopping may use \li
ne \up0 \expndtw-10\charscalex92 the sound of the cash register to locate a sta p
erson. \par\pard\qj \li1551\ri696\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\char
scalex96 Auditory aids for the visually impaired include audiotapes, talking \li
ne \up0 \expndtw-9\charscalex94 books, talking clocks, talking calculators,
and computer applications \line \up0 \expndtw-9\charscalex90 that often mak
e use of accelerated, compressed, or synthetic speech. \line \up0 \expndt
w-9\charscalex97 E\u8260?cient use of these technologies depends on
good hearing, \line \up0 \expndtw-7\charscalex100 eective listening skills, a
nd the ability to retain and process auditory \line \up0 \expndtw-8\charscalex10
0 information. \par\pard\qj \li1551\ri696\sb0\sl-260\slmult0\fi478 \up0 \expndtw
-8\charscalex100 For the visually impaired, listening is destined to rem
ain a \line \up0 \expndtw-10\charscalex95 critical avenue for learning in
the classroom. Heinze \up0 \expndtw-10\charscalex88 (1986) lists a \par\pard
\qj \li1551\ri698\sb0\sl-260\slmult0 \up0 \expndtw-7\charscalex100 number of ski
lls necessary to eectively learn via hearing, including \up0 \expndtw-7\charscal
ex100 the following:
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz123\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
113}{\bkmkend Pg113}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7298 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 93\par\pard\qj \li2093\sb0\sl-240
\slmult0 \par\pard\qj\li2093\ri2768\sb78\sl-240\slmult0 \up0 \expndtw-10\charsca
lex92 Basic levels of concentration and attention \up0 \expndtw-10\charscalex93
Auditory memory skills \par\pard\qj \li2093\ri3322\sb4\sl-260\slmult0 \up0 \expn
dtw-10\charscalex94 Fine discrimination of letter sounds \up0 \expndtw-10\charsc
alex92 Vocabulary development \par\pard\ql \li2093\ri2969\sb0\sl-260\slmult0 \up
0 \expndtw-10\charscalex94 Auditory closure and the use of context \up0 \expndtw
-10\charscalex92 Listening for specic purposes \line \up0 \expndtw-10\charscalex9
3 Selective listening \par\pard\qj \li2093\ri960\sb0\sl-260\slmult0 \up0 \expndt
w-10\charscalex95 Perception of subtle auditory cues that aect meaning, includ\up
0 \expndtw-10\charscalex93 ing intonation, intensity, pitch, and pauses \par\par
d\qj \li1286\ri959\sb140\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 Trad
itionally audiologists have focused primarily on the symbolic \line \up0 \expndt
w-9\charscalex97 level of hearing when providing an assessment. W|th the
visually \line \up0 \expndtw-9\charscalex98 impaired population, it is impo
rtant that we consider all levels of \line \up0 \expndtw-10\charscalex95 a
uditory functioning and the auditory needs of each individual. \par\pard\ql \li1

995\sb0\sl-280\slmult0 \par\pard\ql\li1995\sb0\sl-280\slmult0 \par\pard\ql\li199

5\ri1713\sb24\sl-280\slmult0\tx2919 \up0 \expndtw0\charscalex101 \ul0\nosupersub
\cf7\f8\fs24 ASSESSING HEARING IN THE VISUALLY \line\tab \up0 \expndtw0\charscal
ex102 IMPAIRED POPULATION \par\pard\qj \li1286\ri961\sb257\sl-260\slmult0\fi478
\up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 V|sion loss inuences ho
w an individual copes in the test environ\up0 \expndtw-9\charscalex96 ment, how
we structure our testing, what test materials we select, what \up0 \expndtw-9\ch
arscalex90 kind of responses we expect to see, how we interpret those responses,
and \up0 \expndtw-10\charscalex90 what recommendations we make. \par\pard\qj \l
i1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 By using info
rmation about an individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\
cf2\f3\fs22 s visual function to make \line \up0 \expndtw-9\charscalex95 simple
adaptations to the physical setting and test techniques, the clini-\line \up0 \e
xpndtw-9\charscalex93 cian\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\c
f2\f3\fs22 s goal is to create a test environment that allows him or her to obta
in \line \up0 \expndtw-9\charscalex93 accurate information about hearing, to int
erpret test results in the context \line \up0 \expndtw-7\charscalex100 of the vi
sion loss, and to provide meaningful recommendations. All \line \up0 \expndtw-9
\charscalex98 this should be accomplished with minimal stress to the patient, fa
mily, \line \up0 \expndtw-10\charscalex94 and clinician. \par\pard\ql \li1598\sb
0\sl-207\slmult0 \par\pard\ql\li1598\sb0\sl-207\slmult0 \par\pard\ql\li1598\sb15
0\sl-207\slmult0 \up0 \expndtw0\charscalex107 \ul0\nosupersub\cf7\f8\fs24 I\ul0\
nosupersub\cf31\f32\fs17 NTERACTING WITH\ul0\nosupersub\cf7\f8\fs24 S\ul0\nosup
ersub\cf31\f32\fs17 OMEONE WITH A\ul0\nosupersub\cf7\f8\fs24 V\ul0\nosupersub\c
f31\f32\fs17 ISUAL\ul0\nosupersub\cf7\f8\fs24 I\ul0\nosupersub\cf31\f32\fs17 MP
AIRMENT \par\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri961\sb10\s
l-260\slmult0\fi478 \up0 \expndtw-6\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Wh
en meeting and speaking with children and adults who are \up0 \expndtw-9\charsca
lex96 visually impaired, the clinician should behave in a manner that is sensi\u
p0 \expndtw-9\charscalex93 tive, courteous, and professional. Good manners dicta
te that the clinician \up0 \expndtw-10\charscalex93 should do the following:
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz125\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
114}{\bkmkend Pg114}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2857 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 94\tab \up0 \expndtw-8\charscalex97 \ul0\no
supersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\
pard\qj \li2358\sb0\sl-260\slmult0 \par\pard\qj\li2358\ri694\sb70\sl-260\slmult0
\up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 Speak directly to the
visually impaired person, using his or her \up0 \expndtw-10\charscalex87 name.
\par\pard\qj \li2358\ri695\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex92 Intr
oduce himself or herself and anyone else who may be in the \up0 \expndtw-10\char
scalex93 room. \par\pard\ql \li2358\sb6\sl-253\slmult0 \up0 \expndtw-9\charscale
x100 Do not touch or take hold of the person without warning. \par\pard\qj \li23
58\ri698\sb2\sl-260\slmult0 \up0 \expndtw-10\charscalex95 Speak in a normal
manner. Do not avoid words such as \up0 \expndtw-7\charscalex100 \ul0\nosu
persub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 look\ul0\nosupers
ub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 or \up0 \expndtw-10\
charscalex91 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\
fs22 see\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22

when these words exist as common gures \up0 \expndtw-10\charscalex87 of sp

eech. \par\pard\qj \li2358\ri695\sb0\sl-270\slmult0 \up0 \expndtw-10\charscalex9
4 Be sensitive to stereotypes. Not everyone with a visual impair\up0 \expndtw-8\
charscalex100 ment is a musical prodigy or has developed his or her other \up0 \
expndtw-10\charscalex88 senses to paranormal levels. \par\pard\ql \li2496\sb0\sl
-207\slmult0 \par\pard\ql\li2496\sb0\sl-207\slmult0 \par\pard\ql\li2496\sb1\sl-2
07\slmult0 \up0 \expndtw0\charscalex108 \ul0\nosupersub\cf7\f8\fs24 M\ul0\nosupe
rsub\cf31\f32\fs17 OVING\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\f
s17 BOUT IN THE\ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupersub\cf31\f32\fs17 EST\u
l0\nosupersub\cf7\f8\fs24 E\ul0\nosupersub\cf31\f32\fs17 NVIRONMENT \par\pard\q
j \li1551\sb0\sl-262\slmult0 \par\pard\qj\li1551\ri695\sb6\sl-262\slmult0\fi478
\up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 A person with visual i
mpairment may need assistance to move \line \up0 \expndtw-7\charscalex100 about
in the environment. It is important to be sure that the physical \line \up0 \exp
ndtw-9\charscalex95 setting is as safe as possible. In the test space,
special attention \line \up0 \expndtw-7\charscalex100 should be paid to any po
tential obstacles such as wires that may be \line \up0 \expndtw-9\charscalex98 o
n the oor or boom microphones that can be left pulled out. Be \line \up0
\expndtw-9\charscalex95 aware that lighting levels can have an impact o
n vision. Someone \line \up0 \expndtw-9\charscalex95 who can see well enou
gh to move about easily when the lighting \line \up0 \expndtw-3\charscale
x100 levels are bright may have di\u8260?culty seeing in the dimmer light of a \
line \up0 \expndtw-10\charscalex94 sound booth. \par\pard\qj \li1551\ri694\sb0\s
l-264\slmult0\fi478 \up0 \expndtw-10\charscalex100 When the client moves from on
e area to another, ask if\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosu
persub\cf2\f3\fs22 guided \line \up0 \expndtw-9\charscalex96 assistance\ul0\nosu
persub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 is needed. If as
sistance is required, then oer your arm. An \line \up0 \expndtw-9\charscalex100 a
dult will grasp your elbow whereas a child may hold onto your wrist. \line \up0
\expndtw-9\charscalex93 This position allows you to remain beside and slightly a
head as you walk. \line \up0 \expndtw-10\charscalex97 Doors should be fully open
or closed to avoid accidents. As you move \line \up0 \expndtw-10\charscalex96 t
hrough a doorway, describe where you are going. You may assist the \line \up0 \e
xpndtw-9\charscalex94 person to grasp the door to clear it. Verbally identify an
y obstacles, such \line \up0 \expndtw-6\charscalex100 as steps up or down into t
he booth or wires on the oor. When you \line \up0 \expndtw-9\charscalex92 guide t
he person to a chair, place his or her hand on the back of the chair, \line \up0
\expndtw-9\charscalex96 tell the person that it is a chair, and that you would
like him or her to sit \line \up0 \expndtw-9\charscalex93 down. Make sure that t
he person is aware of any other objects, such as a \line \up0 \expndtw-7\charsca
lex100 boom microphone or table, which may be in the vicinity. If possible, \lin
e \up0 \expndtw-9\charscalex92 ensure that obstacles are removed. In addit
ion to physical guidance, \line \up0 \expndtw-10\charscalex92 a running comme
ntary orienting the visually impaired person to what
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
115}{\bkmkend Pg115}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7292 \up0 \expndtw-8\chars
calex96 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 95\par\pard\qj \li1286\sb0\sl-240

\slmult0 \par\pard\qj\li1286\ri961\sb78\sl-240\slmult0 \up0 \expndtw-9\charscale

x92 the physical space is like, where you are going, and what you are doing is \
up0 \expndtw-10\charscalex92 helpful. \par\pard\qj \li1286\ri961\sb4\sl-260\slmu
lt0\fi478 \up0 \expndtw-9\charscalex100 If guided assistance is declined, then i
t is appropriate to provide \up0 \expndtw-9\charscalex92 verbal guidance. Descri
be the physical space and the location of furniture \up0 \expndtw-5\charscalex10
0 or other objects. When identifying furniture, you may want to give \up0 \expn
dtw-9\charscalex93 a sound cue as well, such as tapping a table, to help the per
son locate it. \up0 \expndtw-9\charscalex95 A cloth of contrasting color on the
back of a chair or reective tape on a \up0 \expndtw-10\charscalex90 threshold or
step can make it easier to see. \par\pard\qj \li1286\ri959\sb0\sl-260\slmult0\fi
478 \up0 \expndtw-10\charscalex95 Warn the person before touching him or he
r. Do not assume \line \up0 \expndtw-7\charscalex100 that the person will se
e you approach. Before using an otoscope or \line \up0 \expndtw-9\charscalex92 p
lacing a headset or insert phones, describe what you are about to \li
ne \up0 \expndtw-10\charscalex94 do. W|th adults you may only need to describe t
he phones or headsets. \line \up0 \expndtw-5\charscalex100 W|th children, you
may wish to let them explore the piece of \line \up0 \expndtw-7\charsca
lex100 equipment before using it. When you use a boom microphone \line
\up0 \expndtw-9\charscalex97 for speech testing, caution the visually impaired p
erson that the micro-\line \up0 \expndtw-4\charscalex100 phone will be placed in
front of him or her and allow the person \line \up0 \expndtw-7\charscalex100
to locate the position of the microphone by touch if necessary. \line
\up0 \expndtw-6\charscalex100 Again, it is important to provide a verbal commen
tary for each step \line \up0 \expndtw-10\charscalex88 of the assessment. \par\p
ard\ql \li1604\sb0\sl-276\slmult0 \par\pard\ql\li1604\sb231\sl-276\slmult0 \up0
\expndtw0\charscalex104 \ul0\nosupersub\cf7\f8\fs24 TESTING ADULTS WITH VISUAL I
MPAIRMENT \par\pard\qj \li1286\sb0\sl-256\slmult0 \par\pard\qj\li1286\ri961\sb5\
sl-256\slmult0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 V
|sually impaired adults are usually able to provide standard, \line \up0
\expndtw-10\charscalex96 unambiguous responses to pure tone and speech t
esting so that \line \up0 \expndtw-9\charscalex94 adaptations of the audiologi
c test battery are not necessary. Adaptations \line \up0 \expndtw-8\charscalex10
0 for testing adults with a visual impairment generally involve obtaining \line
\up0 \expndtw-9\charscalex94 information about the type and degree of visi
on loss (case history), \line \up0 \expndtw-9\charscalex100 modifying the phy
sical environment, and ensuring accessibility to any \line \up0 \expndtw-10\char
scalex92 printed materials. \par\pard\ql \li3687\sb0\sl-207\slmult0 \par\pard\ql
\li3687\sb0\sl-207\slmult0 \par\pard\ql\li3687\sb151\sl-207\slmult0 \up0 \expndt
w0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 ASE\
ul0\nosupersub\cf7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17 ISTORY \par\pard\qj \
li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri960\sb10\sl-260\slmult0\fi478 \u
p0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 A question about the sta
tus of vision should always be included in a \line \up0 \expndtw-9\charscalex94
case history, even if no vision loss is suspected. This question can be as \line
\up0 \expndtw-10\charscalex95 simple as asking whether the person is aware of a
ny problems with the \line \up0 \expndtw-9\charscalex96 eyes or vision. If a vis
ual impairment is reported, then information about
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg

116}{\bkmkend Pg116}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2859 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 96\tab \up0 \expndtw-8\charscalex97 \ul0\no
supersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\
pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri695\sb70\sl-260\slmult0
\up0 \expndtw-9\charscalex94 \ul0\nosupersub\cf2\f3\fs22 the cause of the visio
n loss, specically how vision is aected and under \up0 \expndtw-9\charscalex97 wha
t circumstances the person has di\u8260?culty seeing, will be important to \up0
\expndtw-9\charscalex95 set up the test environment, to interpret the results, a
nd to make appro\up0 \expndtw-10\charscalex91 priate recommendations. \par\pard\
ql \li4196\sb0\sl-207\slmult0 \par\pard\ql\li4196\sb0\sl-207\slmult0 \par\pard\q
l\li4196\sb0\sl-207\slmult0 \par\pard\ql\li4196\sb3\sl-207\slmult0 \up0 \expndtw
0\charscalex109 \ul0\nosupersub\cf7\f8\fs24 L\ul0\nosupersub\cf31\f32\fs17 IGHTI
NG \par\pard\qj \li1551\sb0\sl-265\slmult0 \par\pard\qj\li1551\ri696\sb1\sl-265\
slmult0\fi478 \up0 \expndtw-6\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Simply p
ut, the most common problem with lighting is that it is \line \up0 \expndtw-7\ch
arscalex100 either too bright, resulting in a glare, or is not bright enough. Li
ghting \line \up0 \expndtw-9\charscalex100 in the test setting should be as exib
le as possible. A dimmer switch \line \up0 \expndtw-6\charscalex100 that allows
lighting levels in the sound booth to be adjusted can be \line \up0 \expndtw-10\
charscalex96 helpful. Lighting should be task specic. Table lamps can be placed t
o \line \up0 \expndtw-7\charscalex100 provide optimal lighting. A penlight or ash
light can be used if more \line \up0 \expndtw-5\charscalex100 light is needed fo
r reading printed materials. Minimizing the use of \line \up0 \expndtw-8\charsca
lex100 reective or highly polished surfaces or covering them with cloth will \lin
e \up0 \expndtw-10\charscalex91 help reduce glare. \par\pard\ql \li3651\sb0\sl-2
07\slmult0 \par\pard\ql\li3651\sb0\sl-207\slmult0 \par\pard\ql\li3651\sb0\sl-207
\slmult0 \par\pard\ql\li3651\sb2\sl-207\slmult0 \up0 \expndtw0\charscalex106 \ul
0\nosupersub\cf7\f8\fs24 P\ul0\nosupersub\cf31\f32\fs17 RINTED\ul0\nosupersub\cf
7\f8\fs24 M\ul0\nosupersub\cf31\f32\fs17 ATERIALS \par\pard\qj \li1551\sb0\sl-2
64\slmult0 \par\pard\qj\li1551\ri695\sb2\sl-264\slmult0\fi478 \up0 \expndtw-10\c
harscalex93 \ul0\nosupersub\cf2\f3\fs22 Printed test materials, test instruction
s, and counseling information \up0 \expndtw-9\charscalex94 should be made ava
ilable in large print. A font size of 16 point is \up0 \expndtw-9\char
scalex93 recommended, and a sans serif font, such as Arial or Universal, is easi
er \up0 \expndtw-9\charscalex94 to read. Both capital and small letters should b
e used. Printing should be \up0 \expndtw-8\charscalex100 on a plain background,
on one side of the paper only, and should be \up0 \expndtw-10\charscalex92 space
d to avoid crowding. \par\pard\qj \li1551\ri696\sb0\sl-264\slmult0\fi478 \up0 \e
xpndtw-10\charscalex97 Laminating or placing printed material in a plastic page
protector \line \up0 \expndtw-8\charscalex100 may cause glare. Printed materials
can be mounted instead on light-\line \up0 \expndtw-8\charscalex100 weight card
board to increase durability and to ensure that light does \line \up0 \expndtw-8
\charscalex100 not penetrate the paper when it is held up to read. A handheld ma
g-\line \up0 \expndtw-9\charscalex100 nier, which may come with a light attachmen
t, can be used with any \line \up0 \expndtw-9\charscalex95 printed materials.
If a test involves choosing from a set of written \line \up0 \expndtw-9
\charscalex95 responses, then the printed material should be easy to ho
ld or to \line \up0 \expndtw-10\charscalex95 move close to the visually impair
ed person\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s face
when necessary. For \line \up0 \expndtw-8\charscalex100 example, printed materi
al mounted on cardboard may be lighter and \line \up0 \expndtw-8\charscalex100 e
asier to hold up than papers attached to a clipboard. A slant board
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}

}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
117}{\bkmkend Pg117}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7287 \up0 \expndtw-8\chars
calex96 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 97\par\pard\qj \li1286\sb0\sl-260
\slmult0 \par\pard\qj\li1286\ri961\sb42\sl-260\slmult0 \up0 \expndtw-7\charscale
x100 with a clip to hold printed material, which can be placed on a table in \up
0 \expndtw-9\charscalex100 front of the person being tested, may be another opti
on. \par\pard\ql \li1424\sb0\sl-276\slmult0 \par\pard\ql\li1424\sb0\sl-276\slmul
t0 \par\pard\ql\li1424\sb115\sl-276\slmult0 \up0 \expndtw0\charscalex105 \ul0\no
supersub\cf7\f8\fs24 TESTING CHILDREN WITH VISUAL IMPAIRMENT \par\pard\qj \li128
6\ri960\sb257\sl-261\slmult0\fi478 \up0 \expndtw-10\charscalex97 \ul0\nosupersub
\cf2\f3\fs22 Audiologic testing of visually impaired children presents audiolo-\
line \up0 \expndtw-9\charscalex96 gists with a unique set of challenges. First,
standard pediatric test tech-\line \up0 \expndtw-8\charscalex100 niques involve
a large component of functional vision. This is true not \line \up0 \expndtw-8\c
harscalex100 only for V|sual Reinforcement Audiometry but also for Behavi
oral \line \up0 \expndtw-10\charscalex95 Observation and Conditioned Play Audiom
etry (Gustin, 1997). Second, \line \up0 \expndtw-9\charscalex97 children with vi
sual impairments frequently present with additional dis-\line \up0 \expndtw-9\ch
arscalex97 abilities. A review of the literature by Lechelt and Hall (2000) indi
cated \line \up0 \expndtw-9\charscalex94 that\ul0\nosupersub\cf11\f12\fs22 \u82
16?\u8216?\ul0\nosupersub\cf2\f3\fs22 the frequency of disabilities additional t
o blindness is so high that a \line \up0 \expndtw-9\charscalex100 sample of chil
dren with no additional disabilities other than congenital \line \up0 \expndtw-9
\charscalex94 blindness might not represent the general population of children w
ho are \line \up0 \expndtw-9\charscalex95 congenitally blind\ul0\nosupersub\cf11
\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 (p. 2). Disabilities includ
e developmental delay, brain \line \up0 \expndtw-9\charscalex95 injury, autism,
and physical disabilities such as cerebral palsy. Typically \line \up0 \expndtw9\charscalex96 any one of these disabilities would place the child in the\ul0\no
supersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 di\u8260?cult
to test\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \line \up0 \expndtw-9\charsc
alex95 \ul0\nosupersub\cf2\f3\fs22 category. Finally, vision loss is a low-incid
ence disability. Audiologists in \line \up0 \expndtw-8\charscalex100 general pra
ctice rarely see these children, making it di\u8260?cult to gain \line \up0
\expndtw-10\charscalex93 experience and develop expertise with this population.
\par\pard\qj \li1286\ri960\sb0\sl-264\slmult0\fi478 \up0 \expndtw-8\charscalex1
00 Ideally audiologic testing of children with visual impairment \up0 \ex
pndtw-9\charscalex96 should be done as part of a multidisciplinary assessment, p
articularly if \up0 \expndtw-6\charscalex100 the diagnosis of vision loss is ne
w. Just as it is unrealistic to expect \up0 \expndtw-9\charscalex96 audiologists
to have specic training or experience in the area of visual \up0 \expndtw-7\char
scalex100 impairment, professionals with expertise related to low vision
or \up0 \expndtw-9\charscalex97 blindness generally lack training and experienc
e in the area of hearing \up0 \expndtw-8\charscalex100 impairment. In addition
, children with a dual sensory impairment \up0 \expndtw-9\charscalex95 (i.
e., deafblind) present with dierent needs than either visually impaired \up0 \exp
ndtw-10\charscalex96 or hearing impaired children and require unique management.
A team \up0 \expndtw-9\charscalex93 approach allows professionals and famil
ies to coordinate information \up0 \expndtw-10\charscalex88 and share experti
se (Gustin, 1997). \par\pard\qj \li1286\ri959\sb0\sl-260\slmult0\fi478 \up0 \exp
ndtw-10\charscalex94 Early detection of hearing loss is important both diagnosti
cally and \line \up0 \expndtw-10\charscalex97 for implementing treatment. Normal
hearing should also be conrmed \line \up0 \expndtw-9\charscalex96 as soon as pos
sible to provide appropriate counseling in the context of \line \up0 \expndtw-9\

charscalex96 the vision loss. In our clinic, once a visual impairment is conrmed
or
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
118}{\bkmkend Pg118}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2859 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 98\tab \up0 \expndtw-8\charscalex97 \ul0\no
supersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par\
pard\qj \li1551\sb0\sl-240\slmult0 \par\pard\qj\li1551\ri697\sb106\sl-240\slmult
0 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf2\f3\fs22 when the child is kn
own to have a condition involving vision loss, \up0 \expndtw-10\charscalex90 he
aring testing is among the rst assessments to be scheduled. \par\pard\ql \li2855\
sb0\sl-207\slmult0 \par\pard\ql\li2855\sb0\sl-207\slmult0 \par\pard\ql\li2855\sb
154\sl-207\slmult0 \up0 \expndtw0\charscalex106 \ul0\nosupersub\cf7\f8\fs24 M\ul
0\nosupersub\cf31\f32\fs17 AKING THE\ul0\nosupersub\cf7\f8\fs24 C\ul0\nosupersu
b\cf31\f32\fs17 HILD\ul0\nosupersub\cf7\f8\fs24 M\ul0\nosupersub\cf31\f32\fs17
ORE\ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupersub\cf31\f32\fs17 ESTABLE \par\pard
\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri695\sb10\sl-260\slmult0\fi4
78 \up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 Traditionally, one
method of assessing children who are considered \line \up0 \expndtw-5\charscalex
100 di\u8260?cult to test is to have them return over several sessions for seria
l \line \up0 \expndtw-7\charscalex100 audiograms. Although this can be eective, i
t can also be costly and \line \up0 \expndtw-9\charscalex97 time consuming for f
amilies, children, and clinicians. If the family must \line \up0 \expndtw-9\char
scalex96 travel long distances to the audiology clinic, it may not be feasible.
One \line \up0 \expndtw-8\charscalex100 alternative is to provide the parents or
school with a mediator-based \line \up0 \expndtw-9\charscalex94 conditioning p
rogram that teaches the child a consistent behavioral \line \up0 \expndtw
-10\charscalex94 response to sound. These responses can then be generalized to f
ormal \line \up0 \expndtw-8\charscalex100 behavioral audiologic testing. The adv
antage of this option is that the \line \up0 \expndtw-10\charscalex95 children c
ome to their assessment already familiar with what they must \line \up0 \expndtw
-7\charscalex100 do during testing and the parents arrive with a wealth
of infor-\line \up0 \expndtw-9\charscalex92 mation about what responses t
o expect, what sounds elicit the best \line \up0 \expndtw-7\charscalex100
responses, what is most reinforcing to the child, and what does not \line \up0
\expndtw-10\charscalex92 work (Gustin, 1997). \par\pard\ql \li3949\sb0\sl-207\sl
mult0 \par\pard\ql\li3949\sb0\sl-207\slmult0 \par\pard\ql\li3949\sb150\sl-207\sl
mult0 \up0 \expndtw0\charscalex102 \ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupersub\
cf31\f32\fs17 EST\ul0\nosupersub\cf7\f8\fs24 B\ul0\nosupersub\cf31\f32\fs17 ATT
ERY \par\pard\qj \li1551\ri694\sb250\sl-260\slmult0\fi478 \up0 \expndtw-10\chars
calex96 \ul0\nosupersub\cf2\f3\fs22 As with sighted children, children with
visual impairment are \line \up0 \expndtw-9\charscalex92 assessed using a ba
ttery of tests. Each test must be interpreted in light of \line \up0 \expndtw-9\
charscalex93 the other tests. Test results should make sense and should not cont
radict \line \up0 \expndtw-10\charscalex88 each other. \par\pard\qj \li1551\ri69
6\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex97 The test battery may in
clude both objective and subjective tests. \line \up0 \expndtw-9\charscalex98 Fo
r populations that are considered di\u8260?cult to test, it is tempting to rely
\line \up0 \expndtw-10\charscalex94 heavily on physiologic tests, such as Audito

ry Brainstem Response and \line \up0 \expndtw-8\charscalex100 Otoacoustic Emissi

ons testing. The importance of normal hearing in \line \up0 \expndtw-10\charsca
lex96 both ears for sound localization and the advantage of binaural hearing \li
ne \up0 \expndtw-9\charscalex93 in noisy situations, particularly when there is
limited access to visual cues \line \up0 \expndtw-9\charscalex98 to supplement h
earing, means that for children with vision loss, indivi-\line \up0 \expndtw-9\c
harscalex91 dual ear thresholds should be determined as soon as possible. Physio
logic \line \up0 \expndtw-9\charscalex98 tests are helpful to obtain this
information in very young visually \line \up0 \expndtw-9\charscalex96 impair
ed children or those with additional disabilities. Conrmation
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
119}{\bkmkend Pg119}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7285 \up0 \expndtw-8\chars
calex96 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 99\par\pard\qj \li1286\sb0\sl-260
\slmult0 \par\pard\qj\li1286\ri961\sb42\sl-260\slmult0 \up0 \expndtw-10\charscal
ex95 of behavioral ndings by objective measures can also be reassuring to \up0 \e
xpndtw-10\charscalex92 parents and also to the clinician. \par\pard\qj \li1286\r
i960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex92 When previous audi
ologic testing has been unsuccessful, there \line \up0 \expndtw-8\charscale
x100 is the danger that undue emphasis can be placed on the physiologic \line \u
p0 \expndtw-10\charscalex94 tests. By denition, these tests indicate \up0 \e
xpndtw-10\charscalex94 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupers
ub\cf2\f3\fs22 a patient\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf
2\f3\fs22 s hearing ability \par\pard\qj \li1286\ri960\sb0\sl-260\slmult0 \up0
\expndtw-7\charscalex100 without the patient\ul0\nosupersub\cf11\f12\fs22 \u8
217?\ul0\nosupersub\cf2\f3\fs22 s active participation in the test\ul0\nosu
persub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 and do not \li
ne \up0 \expndtw-10\charscalex97 reect hearing in the sense of \up0 \expndtw
-8\charscalex100 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2
\f3\fs22 meaningful interpretation of the \par\pard\ql \li1286\sb26\sl-253\sl
mult0\tx5546 \up0 \expndtw-10\charscalex93 sound as to produce thought and
language\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \tab \up0 \expndtw-7\chars
calex100 \ul0\nosupersub\cf2\f3\fs22 (Northern & Downs, \par\pard\qj \li1286\r
i959\sb0\sl-266\slmult0 \up0 \expndtw-9\charscalex93 2002). Although we recogn
ize the importance of these tests as part \up0 \expndtw-8\charscalex100 o
f the test battery, it is our conviction that accurate behavioral testing \up0 \
expndtw-9\charscalex97 provides us with the richest information about how
a child hears \up0 \expndtw-10\charscalex92 and uses that hearing. \par\pard
\ql \li3687\sb0\sl-207\slmult0 \par\pard\ql\li3687\sb0\sl-207\slmult0 \par\pard\
ql\li3687\sb166\sl-207\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\
f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 ASE\ul0\nosupersub\cf7\f8\fs24 H\ul0\nos
upersub\cf31\f32\fs17 ISTORY \par\pard\qj \li1286\sb0\sl-265\slmult0 \par\pard\q
j\li1286\ri961\sb1\sl-265\slmult0\fi478 \up0 \expndtw-10\charscalex96 \ul0\nosup
ersub\cf2\f3\fs22 For children, questions should cover standard pediatric
case \line \up0 \expndtw-5\charscalex100 history information, information re
lated to additional disabilities \line \up0 \expndtw-7\charscalex100 that may
have an impact on the testing and information about func-\line \up0 \expndtw-9\
charscalex96 tional vision and hearing. Often information about a child\

ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s formal \line

\up0 \expndtw-10\charscalex93 visual diagnosis, visual acuity measurements,
peripheral visual \up0 \expndtw-10\charscalex96 eld \par\pard\qj \li1286\ri961\
sb0\sl-270\slmult0 \up0 \expndtw-9\charscalex98 defects, or sensitivity to light
is not available before audiologic testing. \up0 \expndtw-7\charscalex100 This
sort of information can be elicited by asking the following \up0 \expn
dtw-10\charscalex88 questions: \par\pard\qj \li2093\ri3738\sb110\sl-260\slmult0
\up0 \expndtw-10\charscalex94 How well does your child see? \line \up0 \expndtw10\charscalex91 Can your child see your face? \par\pard\ql \li2093\sb6\sl-253\sl
mult0 \up0 \expndtw-10\charscalex93 Can your child see you from across the room?
\par\pard\ql \li2093\sb7\sl-253\slmult0 \up0 \expndtw-10\charscalex92 Does your
child see better on one side or the other? \par\pard\qj \li2093\ri1650\sb2\sl-2
60\slmult0 \up0 \expndtw-10\charscalex97 Does your child see better in dim light
or bright light? \up0 \expndtw-10\charscalex95 Does your child like lights? \pa
r\pard\ql \li2093\sb6\sl-253\slmult0 \up0 \expndtw-10\charscalex94 W|ll your chi
ld stare at lights? \par\pard\ql \li2093\sb7\sl-253\slmult0 \up0 \expndtw-9\char
scalex100 Do bright lights bother your child? \par\pard\qj \li2093\ri961\sb2\sl260\slmult0 \up0 \expndtw-10\charscalex93 Does your child look directly at what
he or she is trying to see? \up0 \expndtw-10\charscalex93 Does your child tilt h
is or her head when he or she is looking at \up0 \expndtw-10\charscalex90 someth
ing? \par\pard\qj \li2093\ri1058\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex9
5 Can you get your child to look at something by using sound? \up0 \expndtw-10\c
harscalex88 Do your child\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf
2\f3\fs22 s eyes shake?
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
120}{\bkmkend Pg120}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2905 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 100\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri695\sb70\sl-260\slmult
0\fi478 \up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Most parents c
an provide a great deal of information about their \up0 \expndtw-8\charscalex100
child\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s functio
nal vision. If you know which questions to ask, then you \up0 \expndtw-10\charsc
alex95 will nd that parents usually know the answers. \par\pard\ql \li3082\sb0\sl
-207\slmult0 \par\pard\ql\li3082\sb0\sl-207\slmult0 \par\pard\ql\li3082\sb0\sl-2
07\slmult0 \par\pard\ql\li3082\sb163\sl-207\slmult0 \up0 \expndtw0\charscalex105
\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 DAPTING\ul0\nosupers
ub\cf7\f8\fs24 B\ul0\nosupersub\cf31\f32\fs17 EHAVIORAL\ul0\nosupersub\cf7\f8\f
s24 T\ul0\nosupersub\cf31\f32\fs17 ESTING \par\pard\qj \li1551\sb0\sl-261\slmul
t0 \par\pard\qj\li1551\ri695\sb8\sl-261\slmult0\fi478 \up0 \expndtw-10\charscale
x97 \ul0\nosupersub\cf2\f3\fs22 Adaptations of behavioral testing to accommodate
visual impair-\line \up0 \expndtw-9\charscalex100 ment are divided here into lo
w-technology and high-technology cate-\line \up0 \expndtw-9\charscalex94 gories.
Low-technology suggestions include adaptations that can be \line \up0 \e
xpndtw-9\charscalex100 made with little expense, using household items or versio
ns of audio-\line \up0 \expndtw-9\charscalex97 logic test materials that are com
mercially available. They can often be \line \up0 \expndtw-7\charscalex100 made
on the spot or with a little advanced planning. This category \line \up0 \expn

dtw-6\charscalex100 would probably be most useful to those clinicians who see ch

ildren \line \up0 \expndtw-8\charscalex100 with visual impairment only occasiona
lly in their practices. High-tech-\line \up0 \expndtw-10\charscalex94 nology opt
ions may involve greater expense, customized equipment, \line \up0 \expndtw
-7\charscalex100 and/or equipment that is not typically used in audiologic testi
ng. This \line \up0 \expndtw-8\charscalex100 may be useful to clinicians who see
a number of children with visual \line \up0 \expndtw-10\charscalex97 impairment
regularly. We have found these modications to be useful \line \up0 \expndtw-7\ch
arscalex100 with sighted children and with children who are cognitively or physi
-\line \up0 \expndtw-10\charscalex93 cally challenged as well. \par\pard\ql \li2
942\sb0\sl-253\slmult0 \par\pard\ql\li2942\sb0\sl-253\slmult0 \par\pard\ql\li294
2\sb120\sl-253\slmult0 \up0 \expndtw-2\charscalex100 Adapting the Physical Envir
onment \par\pard\qj \li1551\ri697\sb122\sl-260\slmult0\fi478 \up0 \expndtw-9\cha
rscalex100 Adaptations to the physical environment typically come down to \up0 \
expndtw-10\charscalex96 lighting and background. \par\pard\qj \li1551\ri696\sb0\
sl-262\slmult0\fi478 \up0 \expndtw-9\charscalex97 As with adults, the ability to
adjust lighting levels in the test envir-\line \up0 \expndtw-10\charscalex96 on
ment can make a signicant dierence in a child\ul0\nosupersub\cf11\f12\fs22 \u8217?
\ul0\nosupersub\cf2\f3\fs22 s comfort level and \line \up0 \expndtw-3\charscalex
100 ability to perform during testing. Not all visually impaired children \line
\up0 \expndtw-9\charscalex98 do better in bright light. Some patients wit
h retinal disorders, for \line \up0 \expndtw-5\charscalex100 example, do bett
er in dim light. Similarly, those with normal acuity \line \up0 \expndtw-9\chars
calex95 do not require a lot of contrast to see, whereas others with
visual \line \up0 \expndtw-10\charscalex97 impairment do. When pictures or objec
ts are displayed during testing, \line \up0 \expndtw-9\charscalex95 backgrounds
should be plain and should oer good contrast. It is impor-\line \up0 \expndtw-9\c
harscalex98 tant to be aware of potential problems with glare from lighting sour
ces \line \up0 \expndtw-10\charscalex88 or reective surfaces.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
121}{\bkmkend Pg121}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7201 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 101\par\pard\ql \li1764\sb0\sl-25
3\slmult0 \par\pard\ql\li1764\sb55\sl-253\slmult0 \up0 \expndtw-10\charscalex94
The following are some low-technology adaptations: \par\pard\qj \li2093\ri962\sb
122\sl-260\slmult0 \up0 \expndtw-10\charscalex92 A pair of children\ul0\nosupers
ub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s sunglasses can be used if
lighting levels are \up0 \expndtw-10\charscalex93 uncomfortably bright (Fig. 4.2
). \par\pard\qj \li2093\ri963\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex94 A
hat with a brim, such as a baseball cap, can shade the eyes \up0 \expndtw-10\ch
arscalex95 from overhead lighting. \par\pard\ql \li2093\sb6\sl-253\slmult0 \up0
\expndtw-10\charscalex92 A desk lamp can provide increased or task-specic lightin
g. \par\pard\qj \li2093\ri959\sb0\sl-266\slmult0 \up0 \expndtw-10\charscalex97 P
lain, solid-colored felt, cork, or Dycem boards are best \line \up0 \exp
ndtw-9\charscalex100 for displaying objects or materials. Dycem is partic
ularly \line \up0 \expndtw-8\charscalex100 useful for displaying pictures, becau
se it will help hold them \line \up0 \expndtw-10\charscalex90 in place. \par\par
d\qj \li2093\ri961\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex95 Plain, solid

-colored tablecloths can be used to cover tables or \line \up0 \expndtw-10\chars

calex96 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22
see-through\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs
22 (clear) wheelchair trays, providing a solid color \line \up0 \expndtw-8\char
scalex100 background for improved contrast and reduction in potential \line \up0
\expndtw-10\charscalex87 glare. \par\pard\ql \li1764\sb142\sl-253\slmult0 \up0
\expndtw-10\charscalex94 The following are some high-technology adaptations: \pa
r\pard\qj \li2093\ri961\sb122\sl-260\slmult0 \up0 \expndtw-6\charscalex100 Dimme
r switches on overhead lights in the booth allow for \up0 \expndtw-8\charscalex1
00 exibility in lighting levels. \par\pard\qj \li2093\ri962\sb0\sl-270\slmult0 \u
p0 \expndtw-10\charscalex95 Commercially available light boxes with adjusta
ble lighting \line \up0 \expndtw-8\charscalex100 levels oer greater contrast for
displaying test materials and \line \up0 \expndtw-10\charscalex86 objects. \par
\pard\ql \li3098\sb0\sl-253\slmult0 \par\pard\ql\li3098\sb0\sl-253\slmult0 \par\
pard\ql\li3098\sb31\sl-253\slmult0 \up0 \expndtw-5\charscalex100 Adapting the Te
st Materials \par\pard\qj \li1286\ri960\sb138\sl-264\slmult0\fi478 \up0 \expndtw
-10\charscalex94 The selection of test materials (familiar objects, picture card
s, and \up0 \expndtw-10\charscalex92 play audiometry materials) and how they are
presented or displayed may \up0 \expndtw-10\charscalex96 need to be modied. We m
ust consider how much vision is involved in \up0 \expndtw-9\charscalex94 each ac
tivity. Tasks that can be performed more easily by touch or tasks \up0 \expndtw8\charscalex100 for which touch can supplement vision to make them easier or mor
e \up0 \expndtw-10\charscalex97 interesting will probably work best. \par\pard\q
l \li1764\sb6\sl-253\slmult0 \up0 \expndtw-10\charscalex95 The following are low
-technology adaptations: \par\pard\qj \li2093\ri961\sb118\sl-265\slmult0 \up0 \e
xpndtw-10\charscalex89 Select games that require less vision or that can easily
be accom\up0 \expndtw-10\charscalex93 plished by touch, such as stacking cups or
dropping blocks in a \up0 \expndtw-10\charscalex95 bucket. A tactile board with
circular pieces of diering textures \up0 \expndtw-10\charscalex95 that t into spo
ts on the board may be a more interesting play \up0 \expndtw-10\charscalex96 tas
k for a child with limited vision.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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\sb0\sl-240{\bkmkstart Pg122}{\bkmkend Pg122}\par\pard\li1551\sb0\sl-253\slmult0
\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2
902 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 102\tab \up0 \expn
dtw-8\charscalex96 \ul0\nosupersub\cf5\f6\fs18 Audiologic Rehabilitation for Peo
ple with Disabilities\par\pard\qj \li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551
\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\s
b0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0
\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\s
l-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-22
0\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\
slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\sl
mult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmu
lt0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult
0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0
\par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \p
ar\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par
\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\p
ard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\par
d\qj\li1551\ri727\sb103\sl-220\slmult0\tx2523 \up0 \expndtw-3\charscalex100 Figu
re 4.2 \tab \up0 \expndtw-7\charscalex98 Sunglasses can be used to adjust lighti
ng levels in the test environment \line\up0 \expndtw-7\charscalex97 and thereby
increase a child\ul0\nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18
s comfort level and ability to perform during testing. Toys \line \up0 \expndtw
-6\charscalex100 that produce an auditory or tactile response can be very reinfo
rcing for children who \up0 \expndtw-8\charscalex96 have low vision or blindness
. (Photo printed with permission.) \par\pard\sect\sectd\fs24\paperw8700\paperh13
020\pard\sb0\sl-240{\bkmkstart Pg123}{\bkmkend Pg123}\par\pard\li3306\sb0\sl-241
\slmult0\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb201\sl-241\slmult0
\fi0\tx7203 \up0 \expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 People with
Visual Impairment\tab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22
103\par\pard\qj \li2093\sb0\sl-260\slmult0 \par\pard\qj\li2093\ri961\sb42\sl-260
\slmult0 \up0 \expndtw-8\charscalex100 Building towers of pegs may be easier and
more interesting \up0 \expndtw-8\charscalex100 for a child with low vision than
use of a traditional pegboard \up0 \expndtw-10\charscalex86 (Fig. 4.3). \par\pa
rd\qj \li2093\ri960\sb0\sl-260\slmult0 \up0 \expndtw-9\charscalex100 Have the fa
mily bring a familiar picture book from home that \line \up0 \expndtw-10\charsca
lex93 the child is able to see. An informal speech reception threshold \line \up
0 \expndtw-6\charscalex100 can be obtained by having the child point to pictures
in the \line \up0 \expndtw-10\charscalex96 book. \par\pard\qj \li2093\ri961\sb0
\sl-264\slmult0 \up0 \expndtw-10\charscalex97 Use of individual picture cards of
familiar objects or spondee \line \up0 \expndtw-10\charscalex93 items, such a
s those from the Picture Spondee Threshold \line \up0 \expndtw-10\charscal
ex94 Test, allows the clinician to preferentially select items that \lin
e \up0 \expndtw-10\charscalex100 the child knows, have good contrast, and can be
easily seen \line \up0 \expndtw-10\charscalex91 (Fig. \up0 \expndtw-9\charscale
x100 4.4). Individual cards can be displayed in ways to \line \up0 \expn
dtw-10\charscalex95 accommodate visual crowding, visual \up0 \expndtw-10\char
scalex94 eld losses, or eye \par\pard\qj \li2093\ri962\sb17\sl-260\slmult0 \up
0 \expndtw-10\charscalex95 movement disorders that aect a child\ul0\nosupers
ub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ability to visually \li
ne \up0 \expndtw-10\charscalex80 scan. \par\pard\qj \li2093\ri960\sb0\sl-264\slm
ult0 \up0 \expndtw-10\charscalex97 Body part identication or familiar objects can
be used if pic-\line \up0 \expndtw-2\charscalex100 tures are too di\u8260?cult
for the child to see. Be careful when \line \up0 \expndtw-7\charscalex100 select

ing familiar objects to use with children who are blind \line \up0 \expndtw-8\ch
arscalex100 or severely visually impaired. To a young, blind child, taste, \line
\up0 \expndtw-10\charscalex96 texture, and temperature are among the properties
that allow \line \up0 \expndtw-10\charscalex92 them to identify items such as\u
l0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 ice cream
\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 or\ul0\
nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 popcorn.\ul0
\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 Plastic \li
ne \up0 \expndtw-10\charscalex94 representations of these, which can be used to
assess sighted \line \up0 \expndtw-10\charscalex96 children, may not be appropri
ate for a visually impaired child. \line \up0 \expndtw-10\charscalex90 Real-life
items, such as\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\
f3\fs22 toothbrush\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf
2\f3\fs22 or\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3
\fs22 baseball\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3
\fs22 may be better \line \up0 \expndtw-10\charscalex84 choices. \par\pard\qj \
li2093\ri963\sb0\sl-260\slmult0 \up0 \expndtw-9\charscalex100 A slant board for
displaying picture materials may make pic\up0 \expndtw-10\charscalex91 tures mor
e visually accessible for some children. \par\pard\ql \li1764\sb123\sl-253\slmul
t0 \up0 \expndtw-10\charscalex94 The following are high-technology adaptations:
\par\pard\qj \li2093\ri961\sb142\sl-260\slmult0 \up0 \expndtw-10\charscalex93 Co
mmercially available light boxes can be used to display \line \up0 \expn
dtw-10\charscalex94 familiar objects or pictures. Some familiar object cards tha
t are \line \up0 \expndtw-10\charscalex93 available for purchase with the light
boxes are, in fact, spondee \line \up0 \expndtw-10\charscalex90 items. \par\pard
\qj \li2093\ri960\sb0\sl-266\slmult0 \up0 \expndtw-4\charscalex100 A light box w
ith colored pegs and a grid may be easier to \line \up0 \expndtw-10\charscalex95
use visually or by touch than a traditional pegboard, and \line \up0 \
expndtw-9\charscalex100 the task is more interesting than dropping blocks in a b
ucket \line \up0 \expndtw-10\charscalex86 (Fig. 4.5).
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\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\l
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1\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\
sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb
0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\

sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl

-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-2
20\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220
\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\s
lmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slm
ult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmul
t0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0
\par\pard\qj\li1551\ri728\sb203\sl-220\slmult0\tx2513 \up0 \expndtw-4\charscale
x100 Figure 4.3 \tab \up0 \expndtw-4\charscalex100 A child with low vision may p
refer to build a tower of pegs rather than \line\up0 \expndtw-7\charscalex96 use
a traditional pegboard, because creating a tower may be easier to do by touch a
nd \line \up0 \expndtw-8\charscalex96 more interesting for the child. (Photo pri
nted with permission.) \par\pard\sect\sectd\fs24\paperw8700\paperh13020{\shp
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01451450014514500145145007ffd9}}}}}\pard\sb0\sl-240{\bkmkstart Pg126}{\bkmkend P
g126}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-253\slmult0\par\
pard\li1551\sb137\sl-253\slmult0\fi0\tx2905 \up0 \expndtw-10\charscalex96 \ul0\n
osupersub\cf2\f3\fs22 106\tab \up0 \expndtw-8\charscalex96 \ul0\nosupersub\cf5\f
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lmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slm
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par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \pa
r\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\
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x2506 \up0 \expndtw-5\charscalex100 Figure 4.5 \tab \up0 \expndtw-8\charscalex96
A grid and colored pegs on a light box may make a play audiometry task \line\up
0 \expndtw-7\charscalex100 easier for a child with low vision and may encourage
attention to task. (Photo printed \line \up0 \expndtw-7\charscalex100 with permi
ssion.) \par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkst
art Pg127}{\bkmkend Pg127}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb
0\sl-241\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7199 \up0 \expndtw-8
\charscalex95 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0
\expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 107\par\pard\ql \li3371\sb0
\sl-253\slmult0 \par\pard\ql\li3371\sb55\sl-253\slmult0 \up0 \expndtw-3\charscal
ex100 Adapting Reinforcers \par\pard\qj \li1286\ri959\sb120\sl-262\slmult0\fi478
\up0 \expndtw-7\charscalex100 Much of what is reinforcing about pediatric testi
ng comes from \line \up0 \expndtw-8\charscalex100 vision. Most visually impaired
children do have useful sight and may \line \up0 \expndtw-9\charscalex91 be ab
le to access visual reinforcers. Social reinforcement can also be \line \
up0 \expndtw-9\charscalex100 very eective with visually impaired children. Howeve
r, be aware that \line \up0 \expndtw-9\charscalex93 nonverbal social reinforce
ment, such as smiling, nodding, and using \line \up0 \expndtw-9\charscalex
100 thumbs-up signs, may not be visually accessible to them. We need to \line \u
p0 \expndtw-9\charscalex96 ask ourselves: What is reinforcing about this task? H

ow much of that is \line \up0 \expndtw-9\charscalex94 visual? Does this child ha

ve enough vision to access this reinforcement? \line \up0 \expndtw-10\charscalex
95 Can reinforcement come from another sense, such as touch? How can \line \up0
\expndtw-10\charscalex92 I make the reinforcement more accessible to the child?
\par\pard\ql \li1764\sb166\sl-253\slmult0 \up0 \expndtw-10\charscalex92 V|sual R
einforcement Audiometry \par\pard\ql \li1764\sb127\sl-253\slmult0 \up0 \expndtw10\charscalex95 The following are low-technology adaptations: \par\pard\qj \li20
93\ri960\sb105\sl-280\slmult0 \up0 \expndtw-10\charscalex95 V|sual reinforcers w
ith animation and lights are more versatile \up0 \expndtw-10\charscalex96 than t
hose with lights only. \par\pard\qj \li2093\ri962\sb0\sl-260\slmult0 \up0 \expnd
tw-10\charscalex91 V|sual reinforcers that can be moved about the sound booth ca
n \up0 \expndtw-10\charscalex92 accommodate a number of visual defects. \par\par
d\qj \li2093\ri960\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex93 Removable f
ront panels on shadow boxes allow for easier \up0 \expndtw-10\charscalex9
4 visibility. \par\pard\ql \li1764\sb123\sl-253\slmult0 \up0 \expndtw-10\charsca
lex94 The following are high-technology adaptations: \par\pard\qj \li2093\ri959\
sb140\sl-262\slmult0 \up0 \expndtw-10\charscalex97 Customized visual reinforceme
nt audiometry (VRA) system. \line \up0 \expndtw-9\charscalex100 Our VRA system
uses three sets of animated toys, mounted \line \up0 \expndtw-10\charscalex96 on
two stands that can be adjusted for distance and height or \line \up0 \expndtw8\charscalex100 removed completely from the stands and placed next to the \line
\up0 \expndtw-10\charscalex94 child. This allows us to accommodate for acu
ity problems, \line \up0 \expndtw-10\charscalex96 visual eld defects, and physic
al limitations (i.e., limited head \line \up0 \expndtw-10\charscalex92 and neck
mobility). The toys can be set for lights and animation \line \up0 \expndtw-10\c
harscalex97 or lights only, and the shadow boxes can be opened to allow \line \u
p0 \expndtw-10\charscalex88 better access to the reinforcers (Fig. 4.6). \par\pa
rd\ql \li1764\sb166\sl-253\slmult0 \up0 \expndtw-10\charscalex97 Conditioned Pla
yAudiometry \par\pard\ql \li1764\sb127\sl-253\slmult0 \up0 \expndtw-10\charscale
x95 The following are low-technology adaptations: \par\pard\qj \li2093\ri962\sb1
42\sl-260\slmult0 \up0 \expndtw-10\charscalex89 Chose objects with various shape
s and textures for some version \up0 \expndtw-10\charscalex90 of the traditional
\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 blocks
in a bucket\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs
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\bkmkstart Pg128}{\bkmkend Pg128}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li
1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2904 \up0 \ex
pndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 108\tab \up0 \expndtw-8\charsc
alex96 \ul0\nosupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Dis
abilities\par\pard\qj \li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\
slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\sl
mult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmu
lt0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult
0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0
\par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \p
ar\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par
\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\p
ard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\par
d\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\
qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj
\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\l
i1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1
551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li155
1\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\
ri730\sb103\sl-220\slmult0\tx2501 \up0 \expndtw-6\charscalex100 Figure 4.6 \tab
\up0 \expndtw-8\charscalex94 Sets of animated toys mounted in movable shadow box
es with removable \line\up0 \expndtw-4\charscalex100 covers allow for better vis
ual and tactile access to reinforcers. (Photo printed with \line \up0 \expndtw8\charscalex92 permission.) \par\pard\sect\sectd\fs24\paperw8700\paperh13020\par
d\sb0\sl-240{\bkmkstart Pg129}{\bkmkend Pg129}\par\pard\li3306\sb0\sl-241\slmult
0\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx

7194 \up0 \expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 People withVisual

Impairment\tab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 109\par
\pard\qj \li2093\sb0\sl-260\slmult0 \par\pard\qj\li2093\ri961\sb42\sl-260\slmult
0 \up0 \expndtw-10\charscalex93 Interconnecting pegs or stacking cups may be mor
e interesting \up0 \expndtw-10\charscalex96 and possibly easier to use by touch
if there is a severe visual \up0 \expndtw-10\charscalex97 impairment. \par\pard\
qj \li2093\ri960\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex94 Animated toys
removed from their shadow boxes can be used \up0 \expndtw-10\charscalex95 to pro
vide tactile reinforcement. \par\pard\qj \li2093\ri961\sb0\sl-260\slmult0 \up0 \
expndtw-10\charscalex94 Older children can earn tokens that can be used to buy a
prize \up0 \expndtw-10\charscalex95 at the end of testing. \par\pard\ql \li1764
\sb146\sl-253\slmult0 \up0 \expndtw-10\charscalex94 The following are high-techn
ology adaptations: \par\pard\qj \li2093\ri961\sb122\sl-260\slmult0 \up0 \expndtw
-10\charscalex97 A light box with a grid and colored pegs may be more acces\up0
\expndtw-10\charscalex95 sible visually or by touch. \par\pard\qj \li2093\ri960\
sb0\sl-266\slmult0 \up0 \expndtw-10\charscalex96 A\ul0\nosupersub\cf11\f12\fs22
\u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 ashing stamp\ul0\nosupersub\cf11\f12\f
s22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 that lights up when it is pressed
may be a \up0 \expndtw-7\charscalex100 more interesting task for someone with l
ow vision. For chil\up0 \expndtw-10\charscalex92 dren who can see well enough, a
paper with circles or a path or \up0 \expndtw-10\charscalex93 some other patter
n can be lled with stamps. \par\pard\qj \li2093\ri960\sb0\sl-265\slmult0 \up0 \ex
pndtw-10\charscalex96 A T|ckle Me Elmo or similar toy that gives auditory and ta
ctile \line \up0 \expndtw-10\charscalex93 reinforcement when the child touches i
t in response to a stimu-\line \up0 \expndtw-9\charscalex100 lus can be very mot
ivating. We caution that these should be \line \up0 \expndtw-10\charscalex94 onl
y used with children who are reliable responders because it \line \up0 \expndtw10\charscalex95 can be di\u8260?cult to control for false-positive responses. \p
ar\pard\ql \li2677\sb0\sl-276\slmult0 \par\pard\ql\li2677\sb0\sl-276\slmult0 \pa
r\pard\ql\li2677\sb125\sl-276\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupers
ub\cf7\f8\fs24 INTERPRETING RESPONSES \par\pard\qj \li1286\ri961\sb258\sl-260\sl
mult0\fi478 \up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 The goal o
f modifying our test techniques and materials is to create \up0 \expndtw-9\chars
calex93 an environment that allows the child to give an unambiguous response to
\up0 \expndtw-9\charscalex94 the auditory stimuli. As long as responses are clea
r and consistent, they \up0 \expndtw-9\charscalex91 are adequate for testing
purposes. Clinicians must assess the child\ul0\nosupersub\cf11\f12\fs22 \u
8217?\ul0\nosupersub\cf2\f3\fs22 s \up0 \expndtw-9\charscalex95 baseline state a
nd decide which responses are acceptable. Flexibility in \up0 \expndtw-10\charsc
alex92 following the child\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\c
f2\f3\fs22 s lead is essential. \par\pard\qj \li1286\ri959\sb0\sl-260\slmult0\fi
478 \up0 \expndtw-10\charscalex90 Behavioral responses should be interpreted bey
ond simply presence \up0 \expndtw-9\charscalex91 versus absence. The type, quali
ty, and variety of responses provide impor\up0 \expndtw-9\charscalex94 tant inf
ormation about what a child hears and how he or she uses \up0 \expndtw
-7\charscalex100 that information. It is our practice to record the specic behavi
ors we \up0 \expndtw-9\charscalex94 observed and considered to be responses, whi
ch stimuli elicited the best \up0 \expndtw-10\charscalex97 responses, and how we
modied our testing to obtain this information \up0 \expndtw-10\charscalex90 (Gus
tin & Schoem, 1999).
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s

p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}

}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
130}{\bkmkend Pg130}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2897 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 110\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-264\slmult0 \par\pard\qj\li1551\ri696\sb62\sl-264\slmult
0\fi478 \up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 Once all the a
ppropriate modications have been made, responses \line \up0 \expndtw-9\charscalex
98 must be interpreted in the context of the specic vision loss. A young, \line \
up0 \expndtw-9\charscalex94 blind child may reach for a sound rather than turn h
is or her head or may \line \up0 \expndtw-7\charscalex100 turn his or her\ul0\no
supersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 ear\ul0\nosupe
rsub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 toward the sound r
ather than turning to face the \line \up0 \expndtw-9\charscalex96 sound source,
appearing to localize in the wrong direction. A child with \line \up0 \expndtw-9
\charscalex90 damaged maculas and central vision may develop an\ul0\nosupersub\c
f11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 eccentric gaze,\ul0\nosu
persub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 that \line \up0
\expndtw-9\charscalex94 is, may xate above, below, or to the side of the object o
f interest to see \line \up0 \expndtw-9\charscalex97 it. Nystagmus may increase
if a child is tired, anxious, or trying hard to \line \up0 \expndtw-9\charscalex
94 see. An increase in eye oscillations after an auditory stimulus may mean \lin
e \up0 \expndtw-9\charscalex100 the child is trying to look for what made the so
und and, under certain \line \up0 \expndtw-10\charscalex90 circumstances, could
be interpreted as a behavioral response to sound. \par\pard\qj \li1551\ri696\sb0
\sl-263\slmult0\fi478 \up0 \expndtw-7\charscalex100 We need to be aware that chi
ldren with visual impairment may \line \up0 \expndtw-4\charscalex100 take longer
to respond during testing. A child with low vision may \line \up0 \expndtw-9\ch
arscalex95 need extra time to focus on an object or to scan printed mat
erials. \line \up0 \expndtw-7\charscalex100 Nystagmus can make it more di\u8260?
cult for a child to read. If responses \line \up0 \expndtw-9\charscalex95 requir
e extended eort on the part of the child to use vision, then fatigue \line \up0 \
expndtw-9\charscalex96 may become a factor. Additional disabilities may also int
erfere with the \line \up0 \expndtw-10\charscalex92 child\ul0\nosupersub\cf11\f1
2\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ability to give a clear and rapid re
sponse to sound. \par\pard\ql \li3735\sb0\sl-276\slmult0 \par\pard\ql\li3735\sb0
\sl-276\slmult0 \par\pard\ql\li3735\sb192\sl-276\slmult0 \up0 \expndtw0\charscal
ex105 \ul0\nosupersub\cf7\f8\fs24 MANAGEMENT \par\pard\qj \li1551\ri695\sb249\sl
-270\slmult0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 Aud
iologic ndings should be interpreted, and subsequent recom-\line \up0 \expndtw-9\
charscalex100 mendations made in the context of the vision loss. In the presence
of \line \up0 \expndtw-10\charscalex95 a visual impairment, \up0 \expndtw-9\c
harscalex100 ndings of either normal hearing or hearing \par\pard\ql \li155
1\sb5\sl-253\slmult0 \up0 \expndtw-10\charscalex96 impairment have implications
for the following: \par\pard\qj \li2358\ri698\sb105\sl-280\slmult0 \up0 \expndtw
-10\charscalex97 Development of speech and language, cognitive, motor, and \up0
\expndtw-10\charscalex93 socioemotional abilities \par\pard\ql \li2358\sb3\sl-25
3\slmult0 \up0 \expndtw-9\charscalex100 Communication \par\pard\ql \li2358\sb7\s
l-253\slmult0 \up0 \expndtw-10\charscalex85 Academic success \par\pard\qj \li235
8\ri3775\sb18\sl-240\slmult0 \up0 \expndtw-10\charscalex96 Employment opportunit
ies \line \up0 \expndtw-10\charscalex97 Orientation and mobility \par\pard\ql \l
i2358\ri2139\sb4\sl-260\slmult0 \up0 \expndtw-10\charscalex94 Access to technolo
gy for the visually impaired \up0 \expndtw-10\charscalex93 Therapies that promot
e the use of vision \line \up0 \expndtw-10\charscalex91 Safety skills \par\pard\
ql \li2358\sb6\sl-253\slmult0 \up0 \expndtw-5\charscalex100 Quality of life
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz119\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{

\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}

{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
131}{\bkmkend Pg131}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7213 \up0 \expndtw-8\chars
calex94 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 111\par\pard\qj \li1286\sb0\sl-26
0\slmult0 \par\pard\qj\li1286\ri959\sb42\sl-260\slmult0\fi478 \up0 \expndtw-10\c
harscalex96 Depending on the results of audiologic testing, individuals can
\up0 \expndtw-9\charscalex95 generally be placed into one of three categories: t
hose who are visually \up0 \expndtw-10\charscalex93 impaired but have normal hea
ring, those with some degree of coexisting \up0 \expndtw-7\charscalex100 visual
and hearing impairment, and those who are considered to be \up0 \expndtw-10\char
scalex93 deafblind. Management options vary for each group. \par\pard\ql \li2178
\sb0\sl-207\slmult0 \par\pard\ql\li2178\sb0\sl-207\slmult0 \par\pard\ql\li2178\s
b150\sl-207\slmult0 \up0 \expndtw0\charscalex109 \ul0\nosupersub\cf7\f8\fs24 V\u
l0\nosupersub\cf31\f32\fs17 ISUAL\ul0\nosupersub\cf7\f8\fs24 I\ul0\nosupersub\c
f31\f32\fs17 MPAIRMENT WITH\ul0\nosupersub\cf7\f8\fs24 N\ul0\nosupersub\cf31\f3
2\fs17 ORMAL\ul0\nosupersub\cf7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17 EARING \
par\pard\qj \li1286\sb0\sl-264\slmult0 \par\pard\qj\li1286\ri960\sb2\sl-264\slmu
lt0\fi478 \up0 \expndtw-10\charscalex97 \ul0\nosupersub\cf2\f3\fs22 For visually
impaired children and adults who have normal hear-\line \up0 \expndtw-9\charsca
lex96 ing, management is generally limited to providing information about the \l
ine \up0 \expndtw-8\charscalex100 interaction of vision and hearing. Information
will vary, depending on \line \up0 \expndtw-9\charscalex89 the person\ul0\nosup
ersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s age; the type, degree,
and onset of vision loss; the presence of \line \up0 \expndtw-9\charscalex96 any
additional disabilities; and the specic needs or lifestyle choices of \line \up0
\expndtw-10\charscalex93 each individual. \par\pard\qj \li1286\ri960\sb0\sl-260
\slmult0\fi478 \up0 \expndtw-7\charscalex100 Counseling topics may include,
but are not limited to, the \up0 \expndtw-7\charscalex100 following: \par\p
ard\qj \li2093\ri960\sb138\sl-263\slmult0 \up0 \expndtw-10\charscalex94 Causes o
f transient hearing loss and their impact on someone \line \up0 \expndtw-10\char
scalex95 with a visual impairment. Patients and families should be cau-\line \up
0 \expndtw-10\charscalex97 tioned that temporary or uctuating hearing loss rel
ated to \line \up0 \expndtw-10\charscalex93 upper respiratory tract infections
or excessive cerumen is more \line \up0 \expndtw-10\charscalex93 signicant for th
ose who are visually impaired. Prompt medical \line \up0 \expndtw-10\charscalex9
6 treatment is recommended to ensure that hearing remains as \line \up0 \expndtw
-10\charscalex88 good as possible. \par\pard\qj \li2093\ri960\sb0\sl-260\slmult0
\up0 \expndtw-10\charscalex93 Explicit recommendations about hearing conservati
on, both for \up0 \expndtw-9\charscalex100 children and adults. The potential eec
ts of ototoxic medica\up0 \expndtw-7\charscalex100 tions and noise exposure and
the use of hearing protection \up0 \expndtw-10\charscalex90 when appropriate sho
uld be discussed. \par\pard\qj \li2093\ri960\sb0\sl-265\slmult0 \up0 \expndtw-8\
charscalex100 Communicating under di\u8260?cult listening conditions. Situations
\line \up0 \expndtw-10\charscalex93 in which there is background noise, in whic
h the speaker has a \line \up0 \expndtw-10\charscalex94 soft voice or is speakin
g at a distance, or in which the speaker \line \up0 \expndtw-10\charscalex94 can
not be seen are considered di\u8260?cult listening conditions. \line \up0
\expndtw-10\charscalex95 Sighted people use visual cues to supplement their hea
ring in \line \up0 \expndtw-10\charscalex93 these situations. Depending on the e
nvironment, the amount of \line \up0 \expndtw-10\charscalex93 residual vision, a
nd the visually impaired person\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosuper
sub\cf2\f3\fs22 s ability to use \line \up0 \expndtw-7\charscalex100 this vision

, his or her ability to access compensatory visual \line \up0 \expndtw-10\charsc

alex94 information may be limited. Awareness of what constitutes
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
132}{\bkmkend Pg132}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2898 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 112\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li2358\sb0\sl-255\slmult0 \par\pard\qj\li2358\ri695\sb79\sl-255\slmult
0 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 a di\u8260?cult list
ening situation and ways of compensating under \line \up0 \expndtw-10\charscalex
97 these conditions (i.e., reducing background noise or moving \line \up0 \expn
dtw-10\charscalex91 away from its source, moving closer to the speaker, or adjus
ting \line \up0 \expndtw-10\charscalex96 position or lighting to maximize access
to visual cues) should \line \up0 \expndtw-10\charscalex84 be discussed. \par\p
ard\qj \li1551\ri697\sb141\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 Fo
r children, some additional information should be provided, \up0 \expndtw
-10\charscalex96 including the following: \par\pard\qj \li2358\ri695\sb120\sl-26
0\slmult0 \up0 \expndtw-7\charscalex100 The impact of vision loss on normal audi
tory development. \up0 \expndtw-10\charscalex95 Children who can hear sounds
that originate outside their \up0 \expndtw-10\charscalex94 visual range may
need to be specically taught which of these \up0 \expndtw-8\charscalex100 sounds
are important to them and what they mean. Parents \up0 \expndtw-10\charscalex92
should be counseled that their child\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\no
supersub\cf2\f3\fs22 s responses to sound might \up0 \expndtw-10\charscalex97 be
dierent from those of sighted children. For example, their \up0 \expndtw-10\char
scalex95 child may not turn to face sounds but may be still and listen or \up0 \
expndtw-10\charscalex91 reach for the sound instead. \par\pard\qj \li2358\ri695\
sb3\sl-257\slmult0 \up0 \expndtw-6\charscalex100 The potential impact of visual
impairment on the develop-\line \up0 \expndtw-10\charscalex93 ment of recepti
ve and expressive language skills. Children \line \up0 \expndtw-10\charscal
ex96 with good hearing and good auditory memory may remember \line \up0 \expndtw
-10\charscalex96 and use words that they do not fully understand. These
\line \up0 \expndtw-10\charscalex96 children may appear to be uent talkers, but
comprehension \line \up0 \expndtw-10\charscalex96 skills may lag behind exp
ressive language skills. Parents \line \up0 \expndtw-10\charscalex91 should
be alerted to this fact so that speech and language \line \up0 \expndtw
-8\charscalex100 development can be monitored and intervention arranged if \line
\up0 \expndtw-10\charscalex79 necessary. \par\pard\qj \li2358\ri695\sb1\sl-260\
slmult0 \up0 \expndtw-8\charscalex100 A child with a visual impairment may be
a visual learner. \up0 \expndtw-10\charscalex93 Although we may counsel that
hearing is adequate for the aca\up0 \expndtw-10\charscalex96 demic needs of this
group of children, we should not assume \up0 \expndtw-10\charscalex93 that they
are, in fact, auditory learners. Avisually impaired child \up0 \expndtw-10\char
scalex93 may be a visual learner. Parents should be advised to carefully \up0 \e
xpndtw-10\charscalex91 monitor academic progress. \par\pard\qj \li2358\ri696\sb0
\sl-260\slmult0 \up0 \expndtw-5\charscalex100 Routine monitoring of hearing is r
ecommended even if no \line \up0 \expndtw-10\charscalex91 hearing loss has been
diagnosed. For visually impaired children, \line \up0 \expndtw-10\charscalex89 a
udiologic assessment is recommended at least once a year. \line \up0 \exp

ndtw-6\charscalex100 Hearing may be monitored more often for specic children \lin
e \up0 \expndtw-9\charscalex100 depending on risk factors, age, status of visual
impairment, \line \up0 \expndtw-9\charscalex100 and the child\ul0\nosupersub\c
f11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ability to indicate whether he
or she is having \line \up0 \expndtw-9\charscalex100 any di\u8260?culty hearing
. Adults with vision loss should also have
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
133}{\bkmkend Pg133}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7213 \up0 \expndtw-8\chars
calex94 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 113\par\pard\qj \li2093\sb0\sl-25
0\slmult0 \par\pard\qj\li2093\ri960\sb60\sl-250\slmult0 \up0 \expndtw-10\charsca
lex93 their hearing assessed periodically. Hearing may be monitored \up0 \expndt
w-10\charscalex91 less often for adults, because they will be able to request te
sting \up0 \expndtw-10\charscalex92 if they notice changes in their hearing. \pa
r\pard\ql \li2072\sb0\sl-207\slmult0 \par\pard\ql\li2072\sb0\sl-207\slmult0 \par
\pard\ql\li2072\sb0\sl-207\slmult0 \par\pard\ql\li2072\sb85\sl-207\slmult0 \up0
\expndtw0\charscalex108 \ul0\nosupersub\cf7\f8\fs24 V\ul0\nosupersub\cf31\f32\fs
17 ISUAL\ul0\nosupersub\cf7\f8\fs24 I\ul0\nosupersub\cf31\f32\fs17 MPAIRMENT AN
D\ul0\nosupersub\cf7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17 EARING\ul0\nosupers
ub\cf7\f8\fs24 I\ul0\nosupersub\cf31\f32\fs17 MPAIRMENT \par\pard\qj \li1286\sb
0\sl-257\slmult0 \par\pard\qj\li1286\ri959\sb15\sl-257\slmult0\fi478 \up0 \expnd
tw-7\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Clinically, for individuals prese
nting with concurrent vision and \up0 \expndtw-9\charscalex100 hearing problems,
one sensory system is usually deemed to be more \up0 \expndtw-10\charscalex96 s
ignicantly aected than the other. For example, an individual may be \up0 \expndtw10\charscalex94 treated as a hearing impaired person who does not see too well o
r as a \up0 \expndtw-10\charscalex97 visually impaired person who has some di\u8
260?culty hearing. It is assumed \up0 \expndtw-9\charscalex96 that one sense i
s at least partially able to compensate for the other. \up0 \expndtw-9\chars
calex100 If audiologic testing conrms a hearing loss, then the combined eect \up0
\expndtw-10\charscalex97 of these impairments must be considered. Manageme
nt will vary \up0 \expndtw-10\charscalex95 depending on the clinical prole. \pa
r\pard\qj \li1286\ri960\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex97 C
ounseling topics may include, but are not be limited to, the \up0 \expndt
w-10\charscalex98 following: \par\pard\qj \li2093\ri962\sb140\sl-260\slmult0 \up
0 \expndtw-10\charscalex95 The consideration of any degree of hearing loss as si
gnicant \up0 \expndtw-10\charscalex93 when there is a concomitant vision loss. \p
ar\pard\qj \li2093\ri961\sb9\sl-250\slmult0 \up0 \expndtw-8\charscalex100 The gr
eater impact of mild, uctuating, or transient hearing \up0 \expndtw-7\charscalex
100 loss for visually impaired people who have limited ability to \up0 \expndtw10\charscalex93 supplement their hearing with visual cues. \par\pard\qj \li2093\
ri961\sb2\sl-260\slmult0 \up0 \expndtw-8\charscalex100 The impact of hearing los
s on all levels of auditory function. \line \up0 \expndtw-10\charscalex96 For ex
ample, a unilateral hearing loss should not signicantly \line \up0 \expndtw-10\ch
arscalex93 interfere with speech and language development but can inter-\line \u
p0 \expndtw-7\charscalex100 fere with hearing in di\u8260?cult listening situati
ons and can have \line \up0 \expndtw-10\charscalex96 an impact on the ability to
localize sound, aecting orientation \line \up0 \expndtw-10\charscalex91 and mobi

lity, and personal safety for a person with a vision loss. \line \up0 \expndtw-1
0\charscalex100 The potential impact of the hearing loss on a child\ul0\nosupers
ub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ability to \line \up0 \exp
ndtw-10\charscalex90 access auditory cues during therapy to promote the use of v
ision \line \up0 \expndtw-10\charscalex89 or an adult\ul0\nosupersub\cf11\f12\fs
22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ability to access technology for the vis
ually impaired. \line \up0 \expndtw-7\charscalex100 Management of hearing loss w
ith medical or surgical treat-\line \up0 \expndtw-10\charscalex96 ment or amplica
tion. Hearing loss should be managed more \line \up0 \expndtw-9\charscalex100 ag
gressively, either with medical or surgical treatment when \line \up0 \expndtw-7
\charscalex100 appropriate or with amplication when there is a coexisting \line \
up0 \expndtw-10\charscalex95 visual impairment.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
134}{\bkmkend Pg134}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2895 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 114\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li2358\sb0\sl-263\slmult0 \par\pard\qj\li2358\ri695\sb64\sl-263\slmult
0 \up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 The person\ul0\nosup
ersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ability to use residual
vision to compensate for the \line \up0 \expndtw-10\charscalex91 hearing loss o
r residual hearing for the vision loss. For example, \line \up0 \expndtw-10\char
scalex90 is the person able to see detail well enough to lip-read, see facial \l
ine \up0 \expndtw-10\charscalex95 expressions, or access other visual informatio
n to supplement \line \up0 \expndtw-10\charscalex91 hearing? Awareness of situat
ions in which the person may have \line \up0 \expndtw-6\charscalex100 di\u8260?c
ulty seeing or hearing and ways in which he or she can \line \up0 \expndtw-10\ch
arscalex92 maximize residual vision or hearing should be discussed. \par\pard\ql
\li2358\ri695\sb0\sl-263\slmult0 \up0 \expndtw-10\charscalex95 Team approach to
management. Support personnel for indivi-\line \up0 \expndtw-10\charscalex89 du
al sensory impairments, such as a teacher of the deaf and hard \line \up0 \expnd
tw-10\charscalex95 of hearing and a teacher of the visually impaired, should be
in \line \up0 \expndtw-10\charscalex96 close contact and work together to ensure
that recommenda-\line \up0 \expndtw-10\charscalex92 tions are consistent and se
rvices are administered e\u8260?ciently. \line \up0 \expndtw-8\charscalex100 Ear
ly intervention. If the underlying etiology indicates a pro-\line \up0 \expndtw10\charscalex91 gressive hearing and/or visual impairment, then supports should
\line \up0 \expndtw-10\charscalex94 be put in place early. For example, lip-read
ing and/or sign lan-\line \up0 \expndtw-10\charscalex92 guage can be taught whil
e the person still has residual hearing. \line \up0 \expndtw-10\charscalex93 If
the dual sensory impairment is expected to progress to deaf-\line \up0 \expndtw10\charscalex94 blindness, then cochlear implantation may be performed while \li
ne \up0 \expndtw-10\charscalex94 the person still has enough vision to support t
he adjustment to \line \up0 \expndtw-7\charscalex100 the sound from a cochlear i
mplant and the development of \line \up0 \expndtw-10\charscalex88 speech underst
anding. \par\pard\qj \li2358\ri695\sb0\sl-265\slmult0 \up0 \expndtw-10\charscale
x97 Choice of manual communication. If sign language is recom-\line \up0 \expndt
w-10\charscalex89 mended, either because of the degree of hearing loss or becaus
e \line \up0 \expndtw-10\charscalex94 of an additional disability that aects spee

ch, then the type and \line \up0 \expndtw-9\charscalex100 degree of vision loss
may aect the choice of sign language. \line \up0 \expndtw-9\charscalex100 Eye dis
orders that aect the ability to see ne detail, reduce \line \up0 \expndtw-7\chars
calex100 visual elds, or create scotomas may make it di\u8260?cult for the \line
\up0 \expndtw-10\charscalex96 individual to access some signs. For example, the
American \line \up0 \expndtw-10\charscalex96 Sign Language sign for\ul0\nosuper
sub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 go\ul0\nosupersub\c
f11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 is easier to see than th
e sign for \line \up0 \expndtw-10\charscalex94 the same word in Signed Exact Eng
lish. \par\pard\ql \li4116\sb0\sl-195\slmult0 \par\pard\ql\li4116\sb0\sl-195\slm
ult0 \par\pard\ql\li4116\sb0\sl-195\slmult0 \par\pard\ql\li4116\sb101\sl-195\slm
ult0 \up0 \expndtw0\charscalex107 \ul0\nosupersub\cf7\f8\fs24 D\ul0\nosupersub\c
f31\f32\fs17 EAFBLIND \par\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li155
1\ri697\sb12\sl-260\slmult0\fi478 \up0 \expndtw-9\charscalex87 \ul0\nosupersub\c
f2\f3\fs22 Individuals who are considered to be deafblind or dual sensory impair
ed \line \up0 \expndtw-9\charscalex94 are a unique group requiring unique
management. People who are \line \up0 \expndtw-10\charscalex94 deafblind may
experience the world in a fragmented or limited way.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
135}{\bkmkend Pg135}\par\pard\li3306\sb0\sl-241\slmult0\par\pard\li3306\sb0\sl-2
41\slmult0\par\pard\li3306\sb201\sl-241\slmult0\fi0\tx7215 \up0 \expndtw-8\chars
calex94 \ul0\nosupersub\cf5\f6\fs18 People withVisual Impairment\tab \up0 \expnd
tw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 115\par\pard\qj \li1286\sb0\sl-26
0\slmult0 \par\pard\qj\li1286\ri961\sb42\sl-260\slmult0 \up0 \expndtw-9\charscal
ex97 For these individuals, the world may seem unpredictable or even \u
p0 \expndtw-10\charscalex92 threatening (Miles, 2000). \par\pard\qj \li1286\ri95
9\sb0\sl-262\slmult0\fi478 \up0 \expndtw-10\charscalex95 Denitions of deafblindne
ss vary, but criteria usually include (1) a \line \up0 \expndtw-10\charscalex96
combination of visual impairment and hearing impairment that creates \line \up0
\expndtw-9\charscalex100 di\u8260?culty in communication, mobility, concept
development, access \line \up0 \expndtw-9\charscalex96 to information, devel
opment of independence in daily life activities, \line \up0 \expndtw-10\cha
rscalex94 psychosocial adjustment, and obtaining a vocation, and where (2) these
\line \up0 \expndtw-10\charscalex93 decits create unique needs requiring special
ized services and modied \line \up0 \expndtw-8\charscalex100 educational programs
beyond those provided for individuals who are \line \up0 \expndtw-9\charscalex9
5 deaf or blind or multiply handicapped (Arizona Deafblind Project, 2002). \par\
pard\qj \li1286\ri960\sb0\sl-264\slmult0\fi478 \up0 \expndtw-8\charscalex100 Ver
y few people who are classied as deafblind are completely \line \up0 \expndtw-7\c
harscalex100 without sight or hearing. Most have some residual vision or hearing
. \line \up0 \expndtw-9\charscalex98 Often, additional disabilities are present
in this population. It has been \line \up0 \expndtw-10\charscalex97 reported tha
t as many as 80% of children identied as deafblind have \line \up0 \expndtw-8\cha
rscalex100 additional disabling conditions, including cognitive impair
ment, \line \up0 \expndtw-9\charscalex100 physical handicaps, and social o
r emotional problems \up0 \expndtw-9\charscalex100 (Arizona \par\pard\qj \li12
86\ri961\sb0\sl-266\slmult0 \up0 \expndtw-10\charscalex94 Deafblind Project, 200
2; Miles, 2000). Because deafblindness is a com-\line \up0 \expndtw-9\charscalex
94 bination of vision and hearing loss, there is no single prole for someone \lin

e \up0 \expndtw-6\charscalex100 who is deafblind and, therefore, no single metho

d of managing this \line \up0 \expndtw-9\charscalex100 condition. \par\pard\qj \
li1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex97 The impact o
f deafblindness will depend on a number of factors, \line \up0 \expndtw-9\charsc
alex96 including age of onset, degree and type of vision and hearing loss
, \line \up0 \expndtw-10\charscalex96 stability of each sensory loss, and
intervention provided \up0 \expndtw-10\charscalex96 (Arizona \par\pard\qj \li12
86\ri960\sb0\sl-264\slmult0 \up0 \expndtw-9\charscalex100 Deafblind Project, 20
02). Audiologic management for this population \line \up0 \expndtw-9\charscalex9
3 may include many of the recommendations listed in the previous section. \line
\up0 \expndtw-7\charscalex100 Our goal is to optimize residual hearing with refe
rrals for medical or \line \up0 \expndtw-10\charscalex95 surgical assessments an
d by tting amplication, and to provide useful \line \up0 \expndtw-9\charscalex97 i
nformation about the interaction of the hearing loss and vision loss for \line \
up0 \expndtw-10\charscalex93 each individual. \par\pard\qj \li1286\ri959\sb0\sl265\slmult0\fi478 \up0 \expndtw-9\charscalex100 Early and direct intervention by
professionals who are trained in \line \up0 \expndtw-9\charscalex95 the eld of d
eafblindness, in programs specically designed to meet the \line \up0 \expndtw-9\c
harscalex96 unique needs of these individuals, is required to minimize the impac
t of \line \up0 \expndtw-9\charscalex96 the coexisting visual and hearing proble
ms. Because of the diversity of \line \up0 \expndtw-9\charscalex94 needs, servi
ces can rarely be provided by a single person or agency \line \up0 \expndtw
-10\charscalex94 (Miles, 2000). Management of both children and adults is best p
rovided \line \up0 \expndtw-9\charscalex95 in the context of a team approach, in
volving families, professionals, and \line \up0 \expndtw-10\charscalex82 agencie
s.
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
136}{\bkmkend Pg136}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2895 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 116\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\ql \li3842\sb0\sl-276\slmult0 \par\pard\ql\li3842\sb60\sl-276\slmult0 \up0
\expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 REFERENCES \par\pard\li155
1\sb0\sl-207\slmult0\par\pard\li1551\sb88\sl-207\slmult0\fi0\tx3745 \up0 \expndt
w-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 Arizona Deafblind Project.\tab \u
p0 \expndtw-8\charscalex95 (2002). What is deafblindness? Retrieved from h
ttp://\par\pard\li1551\sb12\sl-207\slmult0\fi239 \up0 \expndtw-8\charscalex95 ww
w.azdb.org/whatsdb.1htm.\par\pard\qj \li1551\ri729\sb0\sl-220\slmult0\tx1790 \up
0 \expndtw-7\charscalex96 Gustin, C. (1997). Audiological testing of children wi
th a visual impairment.The Hearing \line\tab \up0 \expndtw-8\charscalex83 Journa
l, 50(4), 70 ^75. \par\pard\ql \li1551\ri729\sb0\sl-220\slmult0\tx1790\tx1790\tx
1790 \up0 \expndtw-7\charscalex100 Gustin, C., & Schoem, S. R. (1999). Tes
ting hearing in children who are visually \line\tab \up0 \expndtw-5\charscalex
100 impaired: Why, when and how. Paper presented at Here\ul0\nosupersub\cf10\f11
\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s Lookin\ul0\nosupersub\cf10\f11\fs18 \
u8217?\ul0\nosupersub\cf5\f6\fs18 at You, Kid2: \line \tab \up0 \expndtw-7\char
scalex100 The Ninth International Conference on Blind and V|sually Impair
ed Children, \line \tab \up0 \expndtw-8\charscalex93 Calgary, Alberta, Canada.
\par\pard\ql \li1551\ri728\sb0\sl-220\slmult0\tx1790\tx1790 \up0 \expndtw-7\char

scalex92 Heinze,T. (1986). Communication skills (pp. 304 ^314). In Scholl, G. T.

(Ed.). Foundations \line\tab \up0 \expndtw-7\charscalex88 of education for bli
nd and visually handicapped children and youth: Theory and practice. \line \t
ab \up0 \expndtw-8\charscalex88 New York: American Foundation for the Blind. \pa
r\pard\ql \li1551\ri727\sb0\sl-220\slmult0\tx1790\tx1790 \up0 \expndtw-7\charsca
lex92 Hill, E.W. (1986). Orientation and mobility. In Scholl, G. T. (Ed.). Found
ations of education \line\tab \up0 \expndtw-7\charscalex92 for blind and visuall
y handicapped children and youth: Theory and practice. New York: \line \tab \up
0 \expndtw-8\charscalex92 American Foundation for the Blind. \par\pard\qj \li155
1\ri729\sb0\sl-220\slmult0\tx1790 \up0 \expndtw-7\charscalex91 Jacobson, J. T.
(1995). Nosology of deafness. Journal of American Academy of Audiology, \line\ta
b \up0 \expndtw-8\charscalex91 6,15 ^20. \par\pard\ql \li1551\ri729\sb0\sl-210\s
lmult0\tx1790\tx1790 \up0 \expndtw-7\charscalex100 Joint Committee on Infant Hea
ring. (2000, August). Year 2000 Position Statement: \line\tab \up0 \expndtw-5
\charscalex100 Principals and guidelines for early hearing detection and interve
ntion programs \line \tab \up0 \expndtw-8\charscalex86 [Special Issue]. Audiolog
yToday. \par\pard\ql \li1551\ri728\sb1\sl-220\slmult0\fi0\tx1790\tx1790\tx1790\t
x1790 \up0 \expndtw-7\charscalex91 Lechelt, E. C., & Hall, D. L. (2000). The imp
act of vision loss on the development of children \line\tab \up0 \expndtw-8\char
scalex87 from birth to 12 \up0 \expndtw-8\charscalex93 years: A literature re
view. Retrieved from The Canadian National \line \tab \up0 \expndtw-7\charsc
alex97 Institute for the Blind Web site:http://www.cnib.ca/eng/fps/vision_loss/i
ndex.htm. \line \up0 \expndtw-5\charscalex100 Miles, B. \up0 \expndtw-7\charsca
lex97 (2000). Overview on deaf-blindness. Retrieved from DB-Link: Nationa
l \line\tab \up0 \expndtw-5\charscalex100 Information Clearinghouse on Childr
en Who Are Deaf-Blind Web site: http:// \line \tab \up0 \expndtw-6\charscalex
100 www.tr.wou.edu/dblink/overview.htm. \par\pard\ql \li1551\sb11\sl-207\slmult0
\tx3388 \up0 \expndtw-7\charscalex100 National Eye Institute. \tab \up0 \expnd
tw-8\charscalex94 (2001). Anatomy of the eye. National Institutes of Hea
lth. \par\pard\ql \li1790\sb13\sl-207\slmult0 \up0 \expndtw-7\charscalex100 Refe
rence number NEA05. Retrieved from http://www.nei.nih.gov. \par\pard\ql \li1551\
ri729\sb3\sl-220\slmult0\tx1790\tx1790 \up0 \expndtw-5\charscalex100 National Ey
e Institute. (2004). National Eye Health Education Program (NEHEP). \line\tab
\up0 \expndtw-7\charscalex94 Frequently asked questions about low vision. Retrie
ved from http://www.nei.nih.gov/ \line \tab \up0 \expndtw-8\charscalex85 nehep/
faqs.asp. \par\pard\ql \li1551\ri727\sb0\sl-220\slmult0\tx1790\tx1790\tx1790 \up
0 \expndtw-7\charscalex93 National Eye Institute. (2004). Prevalence and causes
of visual impairment and blindness \line\tab \up0 \expndtw-7\charscalex90 among
adults 40 years and older in the United States. V|sion loss from eye diseases wi
ll \line \tab \up0 \expndtw-7\charscalex91 increase as Americans age. Retrieved
from http://www.nei.nih.gov/news/pressreleases/ \line \tab \up0 \expndtw-8\chars
calex83 041204.asp. \par\pard\qj \li1551\ri728\sb0\sl-220\slmult0\tx1790 \up0 \e
xpndtw-7\charscalex95 Northern, J. L., & Downs, M. P. (2002). Hearing i
n children (5th ed.). New York: \line\tab \up0 \expndtw-8\charscalex95 Lippi
ncott,W|lliams & W|lkins. \par\pard\qj \li1551\ri728\sb0\sl-220\slmult0\tx1790 \
up0 \expndtw-7\charscalex88 Scott, E. P., Jan, J. E., & Freeman, R. D. (1995). C
an\ul0\nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 t your child
see? A guide for parents and \line\tab \up0 \expndtw-8\charscalex84 professional
s about young children who are visually impaired \up0 \expndtw-8\charscal
ex88 (3rd ed.). Austin, TX: \par\pard\ql \li1790\sb11\sl-207\slmult0 \up0 \exp
ndtw-5\charscalex100 PRO-ED.
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
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137}{\bkmkend Pg137}\par\pard\ql \li3339\sb0\sl-368\slmult0 \par\pard\ql\li3339\
sb0\sl-368\slmult0 \par\pard\ql\li3339\sb0\sl-368\slmult0 \par\pard\ql\li3339\sb
212\sl-368\slmult0 \up0 \expndtw0\charscalex114 \ul0\nosupersub\cf28\f29\fs32 CH
APTER 5 \par\pard\ql \li2425\sb0\sl-360\slmult0 \par\pard\ql\li2425\sb0\sl-360\s
lmult0 \par\pard\ql\li2425\ri2021\sb19\sl-360\slmult0\tx3183 \up0 \expndtw0\char
scalex90 \ul0\nosupersub\cf29\f30\fs32 Older Adults with Dementia or \line\tab \
up0 \expndtw0\charscalex81 Alzheimer\ul0\nosupersub\cf36\f37\fs32 \u8217?\ul0\no
supersub\cf29\f30\fs32 s Disease \par\pard\ql \li3065\sb0\sl-253\slmult0 \par\pa
rd\ql\li3065\sb116\sl-253\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\
cf2\f3\fs22 Emi Isaki, Ph.D., CCC/SLP \par\pard\ql \li2581\ri2273\sb44\sl-233\sl
mult0\tx3009\tx3147\tx3805 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf6\f7\
fs20 Division of Speech Pathology and Audiology \line\tab \up0 \expndtw-9\charsc
alex100 John A. Burns School of Medicine \line \tab \up0 \expndtw-7\charscalex10
0 University of Hawaii at Manoa \line \tab \up0 \expndtw-7\charscalex100 Honolul
u, HA \par\pard\ql \li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb60\sl-230\sl
mult0 \up0 \expndtw-3\charscalex100 Prevalence of Dementia \par\pard\ql \li2840\
ri1561\sb9\sl-280\slmult0 \up0 \expndtw-1\charscalex100 Hearing Loss in the Norm
al Elderly Population \up0 \expndtw-2\charscalex100 Hearing Loss and Cognitive D
ysfunction \line \up0 \expndtw-2\charscalex100 Ethics of Service Provision \par\
pard\qj \li2840\ri1991\sb1\sl-280\slmult0 \up0 \expndtw-1\charscalex100 Identifi
cation and Evaluation of Dementia \up0 \expndtw-3\charscalex100 Management \par\
pard\ql \li2840\sb42\sl-230\slmult0 \up0 \expndtw0\charscalex102 Summary \par\pa
rd\qj \li2840\ri3996\sb9\sl-280\slmult0 \up0 \expndtw-1\charscalex100 Acknowledg
ments \up0 \expndtw-8\charscalex100 References \par\pard\qj \li1286\sb0\sl-263\s
lmult0 \par\pard\qj\li1286\ri960\sb132\sl-263\slmult0\fi478 \up0 \expndtw-9\char
scalex100 \ul0\nosupersub\cf2\f3\fs22 This chapter reviews how changes in cognit
ion, communication, \line \up0 \expndtw-10\charscalex94 behavior, and emotion as
sociated with dementia or Alzheimer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nos
upersub\cf2\f3\fs22 s disease \line \up0 \expndtw-9\charscalex95 (AD) can aect th
e provision of audiologic services. The problems asso-\line \up0 \expndtw-9\char
scalex95 ciated with hearing loss in the normal aging population can also exist
in \line \up0 \expndtw-9\charscalex100 individuals with dementia or AD. However,
the progressive decline of \line \up0 \expndtw-9\charscalex97 cognitive and com
municative abilities in an individual with dementia or \line \up0 \expndtw-9\cha
rscalex100 AD can make the identication of an actual hearing loss more di\u8260?c
ult, \line \up0 \expndtw-9\charscalex93 especially as the disease progresses int
o the moderate or middle stages. \line \up0 \expndtw-9\charscalex97 Therefore du
ring audiologic evaluation and aural rehabilitation, a team \line \up0 \expndtw9\charscalex100 approach involving the client, family members, caregivers, and h
ealth \line \up0 \expndtw-9\charscalex89 care professionals is needed to en
sure accurate assessment, carry out \line \up0 \expndtw-10\charscalex89 recom
mendations, and provide the best care possible. \par\pard\ql \li4282\sb0\sl-207\
slmult0 \par\pard\ql\li4282\sb57\sl-207\slmult0 \up0 \expndtw-8\charscalex79 \ul
0\nosupersub\cf5\f6\fs18 117 \par\pard\qj \li3067\ri2882\sb0\sl-160\slmult0\fi65
\up0 \expndtw0\charscalex100 \ul0\nosupersub\cf30\f31\fs12 Aural Rehabilitation
for People with Disabilities \line \up0 \expndtw0\charscalex100 Copyright \up0
\expndtw-2\charscalex100 2005, Elsevier Inc. All rights reserved.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
138}{\bkmkend Pg138}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2896 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 118\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\ql \li2915\sb0\sl-276\slmult0 \par\pard\ql\li2915\sb60\sl-276\slmult0 \up0
\expndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 PREVALENCE OF DEMENTIA \par
\pard\qj \li1551\ri695\sb238\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93
\ul0\nosupersub\cf2\f3\fs22 Dementia generally occurs in the elderly population.
Approximately \line \up0 \expndtw-9\charscalex91 5 ^ 8% of individuals older th
an age 65 years have some form of dementia \line \up0 \expndtw-9\charscalex94 wi
ththeincidencedoublingevery 5 years (\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216
?\ul0\nosupersub\cf2\f3\fs22 Dementia,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u821
7?\ul0\nosupersub\cf2\f3\fs22 2003).Ofthevarious \line \up0 \expndtw-7\charscal
ex100 types of dementia, AD is the most common, aecting approximately \line \up0
\expndtw-10\charscalex89 4 million people in the United States (Alzheimer\ul0\no
supersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s Association, 2004).
\par\pard\qj \li1551\ri695\sb0\sl-261\slmult0\fi478 \up0 \expndtw-10\charscalex9
1 Dementia is a broad medical term used to describe dierent types of \line \up0 \
expndtw-9\charscalex92 gradually progressive degenerative diseases aecting the br
ain. Dementia \line \up0 \expndtw-4\charscalex100 is often initially identied by
the individual or family members and \line \up0 \expndtw-9\charscalex91 diagnose
d by physicians and neuropsychologists. The Diagnostic and \line \up0 \ex
pndtw-9\charscalex92 Statistical Manual of Mental Disorders (American Psychiatr
ic Association, \line \up0 \expndtw-9\charscalex94 1994) describes various types
of dementia with specic inclusionary and \line \up0 \expndtw-9\charscalex94 excl
usionary criteria for diagnoses. For instance, an example of an inclu-\line \up0
\expndtw-9\charscalex98 sionary criterion for a diagnosis of dementia of the Al
zheimer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s type i
s \line \up0 \expndtw-9\charscalex93 that the client displays multiple cognitive
decits with progressive decline \line \up0 \expndtw-9\charscalex94 in areas su
ch as memory and executive functions that aect social \line \up0 \expndtw
-9\charscalex100 interaction or employment (DSM-IV ). An example of an exclusion
ary \line \up0 \expndtw-9\charscalex96 criterion for this diagnosis would b
e that the cognitive decits are \line \up0 \expndtw-9\charscalex94 not attr
ibutable to other central nervous system conditions such as \line \up0 \
expndtw-9\charscalex92 cerebrovascular accidents (i.e., stroke) or systemic cond
itions (DSM-IV ). \par\pard\qj \li1551\ri694\sb0\sl-260\slmult0\fi478 \up0 \expn
dtw-10\charscalex94 Recent advancements in the early detection of dementi
a and \line \up0 \expndtw-10\charscalex92 increased awareness by the general po
pulation have caused the number \line \up0 \expndtw-8\charscalex100 of individua
ls identied with the disease to rise. For instance, an esti-\line \up0 \expndtw-9
\charscalex96 mated 7 million individuals in the United States have some form of
mild \line \up0 \expndtw-10\charscalex91 to severe dementia \up0 \expndtw-10\
charscalex90 (\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3
\fs22 Dementia,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \up0 \expndtw-10\cha
rscalex91 \ul0\nosupersub\cf2\f3\fs22 2003). The Alzheimer\ul0\nosupersub\cf11

\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s Association \par\pard\qj \li1551

\ri696\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex96 (2004) estimates that by
the year 2050, 14 million Americans will have \up0 \expndtw-9\charscalex95 AD.
Therefore unless eective medical management or treatment is \up0 \expndtw6\charscalex100 found, the number of individuals with the diagnosis of dementia
will \up0 \expndtw-10\charscalex92 certainly continue to increase. \par\pard\ql
\li2636\sb0\sl-280\slmult0 \par\pard\ql\li2636\ri1824\sb144\sl-280\slmult0\tx322
7 \up0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 HEARING LOSS IN THE N
ORMAL \line\tab \up0 \expndtw0\charscalex103 ELDERLY POPULATION \par\pard\qj \li
1551\ri697\sb257\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 \ul0\nosuper
sub\cf2\f3\fs22 The National Institute on Aging (2002) reported that app
roxi-\line \up0 \expndtw-10\charscalex95 mately one third of Americans older tha
n age 60 years have some type \line \up0 \expndtw-10\charscalex96 of hearing pro
blem, and the incidence increases to about one half of
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
139}{\bkmkend Pg139}\par\pard\li2582\sb0\sl-241\slmult0\par\pard\li2582\sb0\sl-2
41\slmult0\par\pard\li2582\sb201\sl-241\slmult0\fi0\tx7217 \up0 \expndtw-8\chars
calex92 \ul0\nosupersub\cf5\f6\fs18 Older Adults with Dementia or Alzheimer\ul0\
nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s Disease\tab \up0 \
expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 119\par\pard\qj \li1286\sb0\
sl-262\slmult0 \par\pard\qj\li1286\ri959\sb38\sl-262\slmult0\fi0 \up0 \expndtw-9
\charscalex94 the U.S. population for individuals older than age 85 years. Heari
ng loss \line \up0 \expndtw-10\charscalex96 in elderly persons may be attributed
to various causes such as normal \line \up0 \expndtw-9\charscalex93 aging, exce
ss cerumen, noise exposure, medications, infections, injuries, \line \up0 \expnd
tw-9\charscalex98 or genetics (National Institute on Aging, 2002). Presbycusis
, or high-\line \up0 \expndtw-9\charscalex92 frequency hearing loss, is a common
occurrence that has been well docu-\line \up0 \expndtw-9\charscalex91 mented in
individuals as they age.Weinstein (2000) denes presbycusis as \line \up0 \expndt
w-9\charscalex96 a chronic health-related condition described as hearing loss as
sociated \line \up0 \expndtw-9\charscalex94 with aging, which presents as an ins
idious, progressive, high-frequency, \line \up0 \expndtw-10\charscalex93 sensori
neural hearing impairment.\ul0\super\cf34\f35\fs23 *\ul0\nosupersub\cf2\f3\fs22
Thus individuals who have presbycu-\line \up0 \expndtw-10\charscalex93 sis main
ly have problems hearing high-frequency speech sounds, which \line \up0 \expndtw
-10\charscalex97 can aect communication. Therefore individuals with this type of
hear-\line \up0 \expndtw-8\charscalex100 ing loss may have di\u8260?culty unders
tanding normal conversation, espe-\line \up0 \expndtw-9\charscalex100 cially in
noisy environments. To enhance communication abilities and \line \up0 \expndtw-9
\charscalex97 increase quality of life, an audiologist will routinely prescribe
a hearing \line \up0 \expndtw-9\charscalex92 aid or aids or assistive listening
devices and assist in aural rehabilitation. \par\pard\qj \li1286\ri959\sb0\sl-26
5\slmult0\fi478 \up0 \expndtw-7\charscalex100 Another common occurrence that aect
s hearing in the elderly \line \up0 \expndtw-8\charscalex100 population is an a
ccumulation of cerumen (earwax). The buildup of \line \up0 \expndtw-10\charscal
ex97 earwax can cause a conductive hearing loss in older individuals. After \lin
e \up0 \expndtw-9\charscalex93 removal of the cerumen, either hearing may be res
tored or the severity of \line \up0 \expndtw-10\charscalex89 the hearing loss
may be lessened \up0 \expndtw-10\charscalex93 (Allen et al., \up0 \expndtw-

10\charscalex93 2003). The National \par\pard\qj \li1286\ri961\sb0\sl-270\slmul

t0 \up0 \expndtw-9\charscalex100 Institute on Aging (2002) stated that in additi
on to excess cerumen, a \line \up0 \expndtw-9\charscalex100 conductive hearing l
oss can also result from middle ear uid buildup, \line \up0 \expndtw-10\charscale
x95 abnormal bone growth, a punctured eardrum, or middle ear infection. \par\par
d\qj \li1286\ri959\sb0\sl-260\slmult0\fi478 \up0 \expndtw-6\charscalex100 Finall
y, tinnitus is present in the elderly population. T|nnitus is \line \up0 \expndt
w-9\charscalex100 typically described as ringing in the ears and can coexist wit
h hearing \line \up0 \expndtw-9\charscalex94 loss. T|nnitus can occur from expos
ure to loud noise, hearing loss, med-\line \up0 \expndtw-10\charscalex91 ication
s, or health problems such as allergies \up0 \expndtw-10\charscalex94 (Nat
ional Institute on \par\pard\qj \li1286\ri962\sb0\sl-280\slmult0 \up0 \expndtw
-7\charscalex100 Aging, 2002). External noise that masks the tinnitus can be us
ed to \up0 \expndtw-10\charscalex90 lessen the problem. \par\pard\qj \li1286\ri9
59\sb0\sl-264\slmult0\fi478 \up0 \expndtw-10\charscalex94 In general, when an in
dividual has concerns about a hearing prob-\line \up0 \expndtw-10\charscalex96 l
em, a formal evaluation is recommended. This evaluation can involve \line \up0 \
expndtw-9\charscalex94 health care professionals such as an otolaryngologist and
an audiologist \line \up0 \expndtw-9\charscalex94 (National Institute on Aging,
2002). After the hearing evaluation, sugges-\line \up0 \expndtw-9\charscalex91
tions can be made such as the use of a hearing aid or aids for presbycusis \line
\up0 \expndtw-9\charscalex91 or the removal of excess cerumen for improv
ed hearing. Therefore \par\pard\qj \li1286\ri1010\sb173\sl-200\slmult0 \up0 \ex
pndtw-6\charscalex95 \ul0\nosupersub\cf3\f4\fs16 *FromWeinstein, B. E. (2000). G
eriatric audiology. NewYork:Thieme Medical Publishers. Reprinted \up0 \expndtw-7
\charscalex95 by permission.
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140}{\bkmkend Pg140}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2904 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 120\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-250\slmult0 \par\pard\qj\li1551\ri694\sb88\sl-250\slmult
0 \up0 \expndtw-9\charscalex92 \ul0\nosupersub\cf2\f3\fs22 acquiring services fr
om health care professionals who are knowledgeable \up0 \expndtw-8\charscalex100
in hearing function and remediation will be extremely valuable to the \up0 \exp
ndtw-10\charscalex95 individual with a hearing loss. \par\pard\ql \li1714\sb0\sl
-276\slmult0 \par\pard\ql\li1714\sb233\sl-276\slmult0 \up0 \expndtw0\charscalex1

03 \ul0\nosupersub\cf7\f8\fs24 HEARING LOSS AND COGNITIVE DYSFUNCTION \par\pard\

qj \li1551\ri696\sb258\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 \ul0\n
osupersub\cf2\f3\fs22 Commonly occurring problems such as presbycusis and excess
ive \line \up0 \expndtw-8\charscalex100 cerumen that inuence normal hearing in el
derly individuals are also \line \up0 \expndtw-10\charscalex97 evident in indivi
duals with dementia. Thus sensorineural hearing loss, \line \up0 \expndtw-9\char
scalex97 conductive hearing loss, and tinnitus can also occur in this population
. \line \up0 \expndtw-8\charscalex100 In addition to the problems associated wit
h normal aging, individuals \line \up0 \expndtw-9\charscalex100 with dementia or
AD have other obstacles that can inuence hearing \line \up0 \expndtw-9\charscale
x96 ability. Progressive changes in cognition in the areas of attention or
\line \up0 \expndtw-8\charscalex100 working (short-term) memory can aect communi
cation abilities such \line \up0 \expndtw-9\charscalex93 as receptive language s
kills (Hopper, Bayles, & Kim, 2001). In turn, these \line \up0 \expndtw-10\chars
calex95 problems can make the audiologic assessment and aural rehabilitation \li
ne \up0 \expndtw-9\charscalex96 process di\u8260?cult for individuals with demen
tia and the health care profes-\line \up0 \expndtw-10\charscalex96 sionals worki
ng with them. \par\pard\qj \li1551\ri696\sb4\sl-256\slmult0\fi478 \up0 \expndtw8\charscalex100 Individuals with dementia or AD begin to lose cognitive abilitie
s \line \up0 \expndtw-7\charscalex100 progressively over time. Cognition or skil
ls that assist one in thinking \line \up0 \expndtw-9\charscalex97 help individua
ls to function in everyday life. Cognitive skills are neces-\line \up0 \expndtw9\charscalex96 sary for daily activities, work, education, and obtaining new inf
ormation \line \up0 \expndtw-9\charscalex93 or skills (Brookshire, 2003). Areas
of cognition that can become impaired \line \up0 \expndtw-10\charscalex96 with d
ementia or AD include attention, memory, organization, problem \line \up0 \expnd
tw-10\charscalex97 solving, reasoning, judgment, and executive functions \u
p0 \expndtw-10\charscalex94 (Brookshire, \par\pard\qj \li1551\ri695\sb1\sl-260\s
lmult0 \up0 \expndtw-9\charscalex92 2003). Specic cognitive skills such as
selective or divided attention \up0 \expndtw-10\charscalex95 and memory for e
vents and new learning, which inuence communica\up0 \expndtw-9\charscalex98 tion,
begin to deteriorate early in the progression of the disease \up0 \ex
pndtw-10\charscalex90 (Hopper et al., 2001). \par\pard\qj \li1551\ri697\sb0\sl-2
60\slmult0\fi478 \up0 \expndtw-10\charscalex96 In addition to reduced cognitive
skills, a related problem that can \line \up0 \expndtw-10\charscalex95 aect an in
dividual with dementia or AD is depression. Depression may \line \up0 \expndtw-8
\charscalex100 occur if the client recognizes changes in his or her everyday thi
nking \line \up0 \expndtw-10\charscalex96 abilities. Brookshire \up0 \expndtw-10
\charscalex96 (2003) stated that symptoms of depression could \par\pard\qj \li1
551\ri696\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex94 often be mistaken
for symptoms of dementia. Thus depression may \line \up0 \expndtw-9\charscal
ex92 inuence cognitive processes negatively, oftentimes producing a pseudo-\line
\up0 \expndtw-10\charscalex90 dementia (Brookshire, 2003). The pseudodementia ca
n produce character-\line \up0 \expndtw-10\charscalex91 istics similar to those
of dementia with problems evident in memory,
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
141}{\bkmkend Pg141}\par\pard\li2582\sb0\sl-241\slmult0\par\pard\li2582\sb0\sl-2
41\slmult0\par\pard\li2582\sb201\sl-241\slmult0\fi0\tx7203 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Older Adults with Dementia or Alzheimer\ul0\

nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s Disease\tab \up0 \

expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 121\par\pard\qj \li1286\sb0\
sl-263\slmult0 \par\pard\qj\li1286\ri959\sb36\sl-263\slmult0 \up0 \expndtw-9\cha
rscalex96 attention, and orientation (Brookshire, 2003).\ul0\super\cf34\f35\fs
23 *\ul0\nosupersub\cf2\f3\fs22 However, if depression \line \up0 \expndtw-9\c
harscalex97 occurs in conjunction with dementia or AD, cognitive decits
can \line \up0 \expndtw-10\charscalex96 appear to be more severely aected than th
ose in an individual without \line \up0 \expndtw-9\charscalex94 depression. Ther
efore if family members, caregivers, health care profes-\line \up0 \expndtw-9\ch
arscalex94 sionals, or the client with dementia notice any signs of de
pression, \line \up0 \expndtw-9\charscalex97 the client should be referred for a
ppropriate services. The treatment of \line \up0 \expndtw-8\charscalex100 depres
sion may positively inuence how an individual with dementia \line \up0 \expndtw-9
\charscalex98 performs on cognitively demanding tasks and in his or her
daily \line \up0 \expndtw-9\charscalex95 routines. Therefore addressing the
depression before an audiologic \line \up0 \expndtw-7\charscalex100 evaluat
ion and aural rehabilitation is imperative for an individual with \line \up0 \ex
pndtw-9\charscalex100 dementia or AD if one expects him or her to perform to the
best of his \line \up0 \expndtw-10\charscalex93 or her abilities. \par\pard\qj
\li1286\ri959\sb0\sl-263\slmult0\fi478 \up0 \expndtw-10\charscalex92 Schow and N
erbonne (2002) reported that audiologists assume the \line \up0 \expndtw-9\chars
calex96 major role in providing education and instruction about aural rehabilita
-\line \up0 \expndtw-9\charscalex95 tion to clients. However, other disciplines
are often involved in the aural \line \up0 \expndtw-9\charscalex89 rehabilitatio
n process. These professionals can include psychologists, social \line \up0 \exp
ndtw-9\charscalex94 workers, rehabilitation counselors, and speech-language
pathologists \line \up0 \expndtw-9\charscalex94 (Schow & Nerbonne, 2002). I
f the client has cognitive impairments \line \up0 \expndtw-7\charscalex100
in attention or memory due to dementia or AD or exhibits symptoms \line \up0 \ex
pndtw-9\charscalex98 of depression with the dementia that further reduce cogniti
ve abilities, \line \up0 \expndtw-9\charscalex100 then retaining any new informa
tion introduced during aural rehabilita-\line \up0 \expndtw-9\charscalex96 tion
may be unlikely. Clients for whom a hearing aid or aids or assistive \line \up0
\expndtw-6\charscalex100 listening devices are prescribed may exhibit great di\u
8260?culty using the \line \up0 \expndtw-9\charscalex97 devices correctly becaus
e of decreased cognitive abilities. Thus family \line \up0 \expndtw-10\charscale
x94 member or caregiver involvement in the audiologic evaluation and aural \line
\up0 \expndtw-10\charscalex92 rehabilitation process is highly recommended. \pa
r\pard\qj \li1286\ri960\sb0\sl-265\slmult0\fi478 \up0 \expndtw-10\charscalex95 F
amily members and caregivers should be considered as integral \line \up0 \expndt
w-8\charscalex100 team members who can provide additional medical information
and \line \up0 \expndtw-8\charscalex100 client history to assist in the evaluati
on process. They may be able to \line \up0 \expndtw-10\charscalex92 provide more
accurate descriptions of events and give examples of when \line \up0 \expndtw-9
\charscalex93 hearing loss was rst noted and any additional changes in hearing ab
ility. \line \up0 \expndtw-9\charscalex94 Family members and caregivers can assi
st the audiologist by telling him \line \up0 \expndtw-9\charscalex94 or her what
strategies seem to improve hearing in familiar environments. \line \up0 \expndt
w-8\charscalex100 This information can greatly help the audiologist to evaluate
hearing \line \up0 \expndtw-9\charscalex100 loss. In addition, family members or
caregivers have frequent or daily \par\pard\qj \li1286\sb0\sl-200\slmult0 \par\
pard\qj\li1286\ri1010\sb2\sl-200\slmult0\fi0 \up0 \expndtw-6\charscalex88 \ul0\n
osupersub\cf3\f4\fs16 *From Brookeshire, R. H. (2003). Introduction to neurogeni
c communication disorders (6th ed.). Reprinted \up0 \expndtw-7\charscalex88 with
permission.
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
142}{\bkmkend Pg142}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2904 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 122\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\ql \li1551\sb0\sl-258\slmult0 \par\pard\ql\li1551\ri694\sb73\sl-258\slmult
0\tx2030 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf2\f3\fs22 interactions
with the individual with dementia or AD; thus they can \line \up0 \expndtw-9\cha
rscalex95 provide valuable information about the client\ul0\nosupersub\cf11\f12\
fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s communicative abilities. \line\tab \up
0 \expndtw-8\charscalex100 After the audiologic evaluation, the client, family m
embers, and \line \up0 \expndtw-9\charscalex96 caregivers are often provided wit
h verbal information regarding the test \line \up0 \expndtw-9\charscalex92 resul
ts. Because of the cognitive changes of the client, information should \line \up
0 \expndtw-9\charscalex100 be restated by using dierent modalities of communicati
on. Education \line \up0 \expndtw-9\charscalex96 provided in dierent formats by t
he audiologist can also be benecial to \line \up0 \expndtw-9\charscalex95 family
members or caregivers. Educational and instructional information \line \up0 \exp
ndtw-9\charscalex98 can be provided via handouts with pictures and written text.
The infor-\line \up0 \expndtw-4\charscalex100 mation provided to the client wit
h dementia or AD should be easy \line \up0 \expndtw-6\charscalex100 to understan
d and concise to assist with retention of any new infor-\line \up0 \expndtw-10\c
harscalex96 mation (Brookshire, 2003). Pictures on handouts should be clear an
d \line \up0 \expndtw-10\charscalex97 simple to aid in comprehension. Family mem
bers, caregivers, and the \line \up0 \expndtw-7\charscalex100 client can refer t
o the take-home materials if they have questions or \line \up0 \expndtw-10\chars
calex93 require clarication. \par\pard\qj \li1551\ri695\sb3\sl-257\slmult0\fi478
\up0 \expndtw-8\charscalex100 In summary, the cognitive status of an individual
with dementia \line \up0 \expndtw-9\charscalex94 should always be taken into acc
ount during an audiologic evaluation and \line \up0 \expndtw-9\charscalex97 aura
l rehabilitation. The ability to determine what is and is not working, \line \up
0 \expndtw-7\charscalex100 what to do if something becomes problematic, when to
ask for help, \line \up0 \expndtw-7\charscalex100 and whom to ask involves the u
se of cognitive functions. If any area \line \up0 \expndtw-7\charscalex100 in co
gnition is impaired, a presumably simple task can, in reality, be \line \up0 \ex
pndtw-7\charscalex100 immensely di\u8260?cult for an individual with demen
tia. Finally, family \line \up0 \expndtw-10\charscalex95 members or caregivers
should be considered important team members \line \up0 \expndtw-7\charscalex100
who can supply information about functional hearing abilities \line
\up0 \expndtw-10\charscalex94 and pertinent medical issues for the client with
dementia. \par\pard\ql \li2719\sb0\sl-276\slmult0 \par\pard\ql\li2719\sb232\sl-2
76\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7\f8\fs24 ETHICS OF S

ERVICE PROVISION \par\pard\qj \li1551\ri694\sb258\sl-260\slmult0\fi478 \up0 \exp

ndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 The American Speech-Language-He
aring Association (ASHA) in \line \up0 \expndtw-9\charscalex92 2003 provided aud
iologists and speech-language pathologists with a code \line \up0 \expndtw-9\cha
rscalex92 of ethics by which they must abide. These principles and rules govern
the \line \up0 \expndtw-9\charscalex95 services provided by these professionals.
Guidelines are given for what \line \up0 \expndtw-9\charscalex96 constitutes pr
ofessional competence, evaluation of the eectiveness of \line \up0 \expndtw-9\ch
arscalex94 services, discussion of prognosis, and provision of services. As stat
ed in \line \up0 \expndtw-10\charscalex95 the ASHA Code of Ethics (2003), indivi
duals shall be provided services \line \up0 \expndtw-9\charscalex94 only when be
net can reasonably be expected. Thus if an individual with \line \up0 \expndtw-10
\charscalex94 dementia or AD is provided for audiology or speech-language pathol
ogy
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
143}{\bkmkend Pg143}\par\pard\li2582\sb0\sl-241\slmult0\par\pard\li2582\sb0\sl-2
41\slmult0\par\pard\li2582\sb201\sl-241\slmult0\fi0\tx7199 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Older Adults with Dementia or Alzheimer\ul0\
nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s Disease\tab \up0 \
expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 123\par\pard\qj \li1286\sb0\
sl-250\slmult0 \par\pard\qj\li1286\ri959\sb60\sl-250\slmult0 \up0 \expndtw-6\cha
rscalex100 services, it is imperative that the professional inform every
one \up0 \expndtw-9\charscalex95 involved with client care about what results ca
n be realistically expected \up0 \expndtw-10\charscalex87 (Tanner, 2003). \par\p
ard\qj \li1286\ri959\sb2\sl-260\slmult0\fi478 \up0 \expndtw-6\charscalex100 The
individual with dementia or AD may be able to participate \line \up0 \expndtw-8\
charscalex100 actively in services by providing accurate verbal feedback during
the \line \up0 \expndtw-9\charscalex95 mild or early stages of the disease. Serv
ices such as aural rehabilitation \line \up0 \expndtw-9\charscalex90 may be warr
anted in the early stages of dementia; however, as the disease \line \up0 \expnd
tw-9\charscalex89 progresses, professionals, family, or caregivers may instead c
hoose to focus \line \up0 \expndtw-4\charscalex100 on quality of life. If a clie
nt with dementia either refuses to use an \line \up0 \expndtw-9\charscalex93 amp
lication device or cannot use one because of cognitive decline, then \line \up0 \
expndtw-9\charscalex95 other means of communication must be investigated.
Therefore the \line \up0 \expndtw-10\charscalex96 audiologist or speech-languag
e pathologist working with the individual \line \up0 \expndtw-10\charscalex93 wi
th dementia must use his or her knowledge and professional judgment \line \up0 \
expndtw-9\charscalex94 when providing services. If professionals disregard the d
egenerative and \line \up0 \expndtw-9\charscalex95 progressive nature of the
dementia and instead choose to provide \line \up0 \expndtw-10\charscalex95
unneeded or inadequate services that do not benet the client, then he \line \up0
\expndtw-10\charscalex96 or she has breached the code of ethics (ASHA, 2003). I
f this occurs, a \line \up0 \expndtw-9\charscalex94 special board appointed byAS
HAwill review the case for the violation(s). \par\pard\ql \li1301\sb0\sl-276\slm
ult0 \par\pard\ql\li1301\sb231\sl-276\slmult0 \up0 \expndtw0\charscalex105 \ul0\
nosupersub\cf7\f8\fs24 IDENTIFICATION AND EVALUATION OF DEMENTIA \par\pard\qj \l
i1286\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb1\sl-258\slmult0\fi478 \up0
\expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 Family members are often t

he rst to recognize changes such as \line \up0 \expndtw-10\charscalex93 early sym

ptoms of dementia in a loved one. For instance, a spouse may \line \up0 \expndtw
-9\charscalex97 notice that his wife or her husband has di\u8260?culty recalling
appointments, \line \up0 \expndtw-9\charscalex95 names of people, and famil
iar places. At times, the individual with \line \up0 \expndtw-9\charscalex
95 dementia may feel anxious, frightened, or lost in his or her surroundings \li
ne \up0 \expndtw-9\charscalex94 and notice that something is wrong. The individu
al may recognize subtle \line \up0 \expndtw-9\charscalex95 changes in his or her
ability to recall new and recent information. These \line \up0 \expndtw-7\chars
calex100 incidents may cause the individual or family to question whether the \l
ine \up0 \expndtw-10\charscalex95 family member actually has dementia or whether
another problem may \line \up0 \expndtw-10\charscalex95 be contributing to the
change in cognition. When questions arise about \line \up0 \expndtw-9\charscalex
93 dementia, a physician such as a neurologist, gerontologist, or related
\line \up0 \expndtw-9\charscalex96 professional, such as a neuropsychologist, w
ill use formal and informal \line \up0 \expndtw-9\charscalex94 examinations and
standardized tests to determine whether the individual \line \up0 \expndtw-10\ch
arscalex97 has dementia, the severity of the dementia, and the type of dementia.
\line \up0 \expndtw-9\charscalex93 Of the evaluation tools available, the most
frequently used screening tool \line \up0 \expndtw-9\charscalex93 to detect an
d determine severity of dementia is the Mini Mental
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53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2905 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 124\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-256\slmult0 \par\pard\qj\li1551\ri695\sb77\sl-256\slmult
0 \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 State Exam (MMSE) (F
olstein, Folstein, & McHugh, 1975). The MMSE \line \up0 \expndtw-9\charscalex96
screens an individual for orientation to time and place, attention, recep-\line
\up0 \expndtw-9\charscalex93 tive and expressive language, constructional abilit
ies, and immediate and \line \up0 \expndtw-10\charscalex94 delayed memory. Score
s on the MMSE are often used to determine the \line \up0 \expndtw-9\charscalex97
severity of cognitive decits. For example, scores from 21 to 25 points \line \up
0 \expndtw-10\charscalex96 indicate mild dementia, scores from 11 to 20 points
indicate moderate \line \up0 \expndtw-10\charscalex90 dementia, and scores of
10 \up0 \expndtw-10\charscalex91 points or less indicate severe dementia.
\par\pard\qj \li1551\ri696\sb1\sl-260\slmult0 \up0 \expndtw-9\charscalex100 Aft
er the initial results of the MMSE, more in-depth neuropsychologic \up0 \expndtw
-9\charscalex97 examinations that provide a more detailed picture of retained co
gnitive \up0 \expndtw-10\charscalex91 abilities can be administered. \par\pard\q
j \li1551\ri696\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91 In additi
on to the neuropsychologic tests, speech-language patholo-\line \up0 \expndtw-9\
charscalex94 gists often use formal standardized tests to assess communication s
kills \line \up0 \expndtw-6\charscalex100 in individuals with dementia or AD. Th
ese tests include the Arizona \line \up0 \expndtw-9\charscalex100 Battery for Co
mmunication Disorders in Dementia (ABCD) (Bayles & \line \up0 \expndtw-9\charsca
lex100 Tomoeda, 1993) for individuals with mild to moderate AD and the \li
ne \up0 \expndtw-9\charscalex100 Functional Linguistic Communication Inventor

y \up0 \expndtw-9\charscalex100 (FLCI) \up0 \expndtw-10\charscalex95 (Bayles &

\par\pard\qj \li1551\ri694\sb2\sl-258\slmult0 \up0 \expndtw-10\charscalex94 Tomo
eda, 1994) for individuals with moderate to severe AD. The ABCD \line \up0 \expn
dtw-9\charscalex95 is designed to identify functional linguistic communication d
ecits asso-\line \up0 \expndtw-9\charscalex97 ciated with AD. The ABCD assists th
e clinician to evaluate orientation, \line \up0 \expndtw-9\charscalex94 immediat
e and delayed recall abilities, auditory comprehension, new \line \up0 \ex
pndtw-9\charscalex93 learning, expressive language, reading comprehensio
n, generative \line \up0 \expndtw-10\charscalex97 naming, semantic knowledge,
and drawing. The clinician can give the \line \up0 \expndtw-7\charscalex100 test
at dierent stages of dementia to determine what cognitive and \line \up0 \expnd
tw-9\charscalex94 communicative skills an individual retains and what skills hav
e changed. \line \up0 \expndtw-9\charscalex100 The results can provide valuable
information about what strategies to \line \up0 \expndtw-10\charscalex96 impleme
nt in the client\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22
s life to enhance his or her communication and \line \up0 \expndtw-9\charscalex
95 daily activities. In addition, the results can assist family members t
o \line \up0 \expndtw-10\charscalex92 determine what can be done about safety is
sues for the client. \par\pard\qj \li1551\ri694\sb1\sl-260\slmult0\fi478 \up0 \e
xpndtw-10\charscalex91 The FLCI is another commonly used test that assesses impa
irments \line \up0 \expndtw-9\charscalex96 in functional communication. This sta
ndardized test is used to evaluate \line \up0 \expndtw-9\charscalex98 clients in
the later stages of dementia, particularly of the AD type. The \line \up0 \expn
dtw-10\charscalex91 areas examined in the FLCI include memory, expressive langua
ge, recep-\line \up0 \expndtw-10\charscalex93 tive language, writing, comprehens
ion of signs, reading comprehension, \line \up0 \expndtw-10\charscalex93 pragmat
ics, and gestures. Results obtained from the FLCI can guide the \line \up0 \expn
dtw-9\charscalex97 clinician in counseling family or caregivers about the types
of compen-\line \up0 \expndtw-10\charscalex92 satory strategies needed to improv
e communication and quality of life. \par\pard\qj \li1551\ri696\sb0\sl-260\slmul
t0\fi478 \up0 \expndtw-7\charscalex100 Both the ABCD and the FLCI can provide va
luable information \line \up0 \expndtw-9\charscalex97 about attention, memory,
and auditory comprehension abilities. If,
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145}{\bkmkend Pg145}\par\pard\li2582\sb0\sl-241\slmult0\par\pard\li2582\sb0\sl-2
41\slmult0\par\pard\li2582\sb201\sl-241\slmult0\fi0\tx7199 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Older Adults with Dementia or Alzheimer\ul0\
nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s Disease\tab \up0 \
expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 125\par\pard\qj \li1286\sb0\
sl-256\slmult0 \par\pard\qj\li1286\ri960\sb49\sl-256\slmult0 \up0 \expndtw-10\ch
arscalex95 indeed, a client has problems with cognition and communication rather
\line \up0 \expndtw-9\charscalex90 than an actual hearing loss, standardized te
sts and an auditory assessment \line \up0 \expndtw-9\charscalex96 can assist to
identify the dierence. Therefore working with other health \line \up0 \expndtw-10
\charscalex96 care professionals as a team to determine whether a true hearing l
oss \line \up0 \expndtw-9\charscalex95 exists or whether the problem is actually
related to a decrease in cogni-\line \up0 \expndtw-7\charscalex100 tion and com
munication is essential in the care of an individual with \line \up0 \expndtw-10
\charscalex95 dementia or AD. \par\pard\qj \li1286\ri960\sb2\sl-259\slmult0\fi47

8 \up0 \expndtw-10\charscalex91 In addition to the screening tools and formal ev

aluation tests used to \line \up0 \expndtw-9\charscalex93 detect changes in cogn
ition and communication, the Global Deterioration \line \up0 \expndtw-9\charscal
ex94 Scale (GDS) (Reisberg, Ferris, de Leon, & Crook, 1982) is often used to \li
ne \up0 \expndtw-9\charscalex100 categorize an individual\ul0\nosupersub\cf11\f1
2\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s dementia or AD into the mild, modera
te, or \line \up0 \expndtw-9\charscalex91 severe stages of disease progression.
The GDS involves observations of a \line \up0 \expndtw-9\charscalex91 client wit
h dementia; therefore scoring is based on the subjective judgment \line \up0 \ex
pndtw-9\charscalex89 of the observer. Seven stages of cognitive decline are desc
ribed with scores \line \up0 \expndtw-9\charscalex93 of 2 to 3 corresponding to
the mild stages of the disease, 4 to 5 indicating \line \up0 \expndtw-9\charscal
ex87 moderate stages, and 6 to 7 associated with the severe stages of the diseas
e. \line \up0 \expndtw-9\charscalex96 A score of 1 indicates that the client is
functioning normally without any \line \up0 \expndtw-9\charscalex94 cognitive de
cline being observed. An individual with dementia in the mild \line \up0 \expndt
w-7\charscalex100 stages often exhibits di\u8260?culties in working (short-term
) and episodic \line \up0 \expndtw-6\charscalex100 (event) memory involved wi
th the retention of new information \line \up0 \expndtw-9\charscalex98 (Hop
per et al., 2001). For instance, an individual may forget his or her \line \up0
\expndtw-9\charscalex93 destination of travel or directions to reach the destina
tion. This change in \line \up0 \expndtw-9\charscalex92 memory function can caus
e the individual with dementia to become afraid \line \up0 \expndtw-9\charscalex
95 and fearful. Later in the mild stage, memory skills become progressively \lin
e \up0 \expndtw-9\charscalex93 worse. Problems can occur with the ability to rec
all names of new people \line \up0 \expndtw-9\charscalex100 and remember new loc
ations. In addition, attention and word retrieval \line \up0 \expndtw-9\charscal
ex93 skills may become impaired, but the individual should be able to continue \
line \up0 \expndtw-9\charscalex94 interacting socially. Anxiety about changes in
cognitive abilities may also \line \up0 \expndtw-9\charscalex93 be observed.
Because of the cognitive and communicative changes \line \up0 \expndtw-9\c
harscalex98 involved, the individual may begin displaying some di\u8260?culty fu
nctioning \line \up0 \expndtw-10\charscalex94 in his or her work environments. \
par\pard\qj \li1286\ri961\sb1\sl-260\slmult0\fi478 \up0 \expndtw-9\charscalex100
During the mild stages of dementia identied using the GDS, an \line \up0 \expndt
w-9\charscalex93 audiologic referral and formal assessment for hearing ability w
ould assist \line \up0 \expndtw-9\charscalex100 the client if any problems were
noted. The individual with dementia or \line \up0 \expndtw-9\charscalex95 AD wou
ld be able to participate actively in the formal audiologic assess-\line \up0 \e
xpndtw-9\charscalex94 ment during the mild stages. If amplication for hearing los
s was recom-\line \up0 \expndtw-9\charscalex92 mended after the assessment, the
use of a hearing aid or aids or listening \line \up0 \expndtw-9\charscalex92 dev
ice would assist the client by improving hearing function for
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
146}{\bkmkend Pg146}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
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0 \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 comprehension of com

munication. This change would benet the client \line \up0 \expndtw-9\charscalex95
in his or her familiar and unfamiliar surroundings for everyday activities. \li
ne \up0 \expndtw-10\charscalex92 However, as the client\ul0\nosupersub\cf11\f12\
fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s dementia or AD progresses, supervision
may be \line \up0 \expndtw-9\charscalex96 needed to assist the client to recall
where and how to store the device, \line \up0 \expndtw-10\charscalex97 how to u
se the hearing device properly (i.e., adjusting the volume and \line \up0 \expnd
tw-9\charscalex94 changing the batteries), and what to do if problems arise with
the device. \par\pard\qj \li1551\ri696\sb1\sl-260\slmult0\fi478 \up0 \expndtw-8
\charscalex100 During the moderate stages of dementia, the client may exhibit \l
ine \up0 \expndtw-9\charscalex94 increased decits in working and episodic memory
(Hopper et al., 2001). \line \up0 \expndtw-9\charscalex96 For instance, events t
hat occurred recently, such as going to a doctor\ul0\nosupersub\cf11\f12\fs22 \u
8217?\ul0\nosupersub\cf2\f3\fs22 s \line \up0 \expndtw-7\charscalex100 appointme
nt or visiting a friend, may not be recalled. Reisberg et al. \line \up0 \expndt
w-9\charscalex90 (1982) stated that problems could also be detected in attention
, orientation, \line \up0 \expndtw-9\charscalex93 judgment, and problem solving.
Familiar activities such as paying house-\line \up0 \expndtw-9\charscalex98 hol
d bills may not be completed. During stage 5, the client will require \line \up0
\expndtw-9\charscalex91 supervision and outside assistance to maintain personal
safety and to per-\line \up0 \expndtw-9\charscalex94 form activities of daily l
iving (Reisberg et al., 1982). Familiar information, \line \up0 \expndtw-7\chars
calex100 such as the client\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\
cf2\f3\fs22 s address, will not be recalled. Supervision will be \line \up0 \exp
ndtw-9\charscalex93 required when the client uses any hearing amplication device
during the \line \up0 \expndtw-9\charscalex91 moderate stages of dementia. Conti
nued assistance will be required to use \line \up0 \expndtw-10\charscalex91 and
care for the hearing device correctly. Any recommendations made by \line \up0 \e
xpndtw-9\charscalex95 the audiologist or other professionals involved in aural r
ehabilitation will \line \up0 \expndtw-10\charscalex91 require the assistance of
family or caregivers for follow-through. \par\pard\qj \li1551\ri695\sb2\sl-258\
slmult0\fi478 \up0 \expndtw-10\charscalex91 Finally, in the severe stages of dem
entia, cognitive and communica-\line \up0 \expndtw-8\charscalex100 tion skills c
ontinue to deteriorate, and the individual will require assis-\line \up0 \expndt
w-9\charscalex96 tance for daily care (Reisberg et al., 1982). Individuals with
dementia in \line \up0 \expndtw-10\charscalex94 the severe stages begin to forge
t the names of familiar family members \line \up0 \expndtw-10\charscalex97 and l
ong-term personal information. Changes begin to emerge in per-\line \up0 \expndt
w-8\charscalex100 sonality, behavior, and emotion. For instance, the individual
may act \line \up0 \expndtw-9\charscalex95 out violently toward family membe
rs or caregivers. Reisberg et al. \line \up0 \expndtw-7\charscalex100 (1982
) reported that during stage 7, the client would lose all ability to \line \up0
\expndtw-9\charscalex95 communicate and require constant care for activities of
daily living such \line \up0 \expndtw-9\charscalex93 as eating and toileting. Th
e authors also stated that the physical ability to \line \up0 \expndtw-9\charsca
lex100 walk would be lost during this stage. Thus the use of an amplication \line
\up0 \expndtw-9\charscalex94 device for hearing may not be ethically warranted
during the later stages \line \up0 \expndtw-8\charscalex100 of disease unless th
e device improves quality of life. When the client \line \up0 \expndtw-9\charsca
lex95 is unable to comprehend information because of cognitive decline,
\line \up0 \expndtw-9\charscalex95 amplifying the client\ul0\nosupersub\cf11\f12
\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s hearing will not change his or her co
mprehension \line \up0 \expndtw-9\charscalex91 abilities. Therefore during the
severe stages of the disease, the focus \line \up0 \expndtw-10\charscale
x91 should be on providing comfort to the client.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
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calex93 \ul0\nosupersub\cf5\f6\fs18 Older Adults with Dementia or Alzheimer\ul0\
nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s Disease\tab \up0 \
expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 127\par\pard\ql \li3470\sb0\
sl-276\slmult0 \par\pard\ql\li3470\sb13\sl-276\slmult0 \up0 \expndtw0\charscalex
105 \ul0\nosupersub\cf7\f8\fs24 MANAGEMENT \par\pard\qj \li1286\ri959\sb238\sl-2
60\slmult0\fi478 \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 As p
reviously reviewed, when individuals age, high-frequency \line \up0 \expndt
w-9\charscalex97 hearing loss is often encountered (National Institute on Aging
, 2002). \line \up0 \expndtw-10\charscalex93 Thus audiologic evaluations should
be completed regularly to determine \line \up0 \expndtw-9\charscalex94 whether
any aural intervention or rehabilitation is necessary. In addition, \line \up0 \
expndtw-9\charscalex94 if hearing assessments are completed regularly, the
audiologist can \line \up0 \expndtw-10\charscalex96 monitor any changes in he
aring ability. Therefore hearing assessment \line \up0 \expndtw-8\charscalex100
should also be done, even though an individual has the diagnosis of \line \up0 \
expndtw-7\charscalex100 dementia or AD. Family members, along with physicians an
d health \line \up0 \expndtw-9\charscalex93 care professionals, must work as a t
eam if they suspect that an individual \line \up0 \expndtw-9\charscalex100 with
dementia or AD has a hearing loss (Schow & Nerbonne, 2002). \line \up0 \expndt
w-3\charscalex100 At times it can be di\u8260?cult to determine whether the hear
ing loss is \line \up0 \expndtw-8\charscalex100 aecting communication and compreh
ension of language or whether \line \up0 \expndtw-9\charscalex100 the actual rea
son stems from overall cognitive decline. Therefore if a \line \up0 \expndtw-4\c
harscalex100 hearing loss is identied in individuals with dementia or AD within \
line \up0 \expndtw-9\charscalex93 the mild or early stages of the disease, then
an active dialogue can occur \line \up0 \expndtw-10\charscalex93 between the aud
iologist and client. \par\pard\qj \li1286\ri960\sb2\sl-258\slmult0\fi478 \up0 \e
xpndtw-10\charscalex97 As an individual progressively loses his or her cognitive
abilities, \line \up0 \expndtw-9\charscalex92 less accurate information, dec
reased interaction, and participation are \line \up0 \expndtw-8\charscalex10
0 expected from the client. For instance, the client may experience di\u8260?-\l
ine \up0 \expndtw-9\charscalex96 culty in active participation in an audio
logic evaluation because of \line \up0 \expndtw-8\charscalex100 changes in em
otion, memory, and attention. If specic directions are \line \up0 \expndtw-9\char
scalex97 provided to the client, he or she may forget the instructions
and \line \up0 \expndtw-9\charscalex91 become easily distracted. Therefore sev
eral short evaluation sessions may \line \up0 \expndtw-9\charscalex94 be necess
ary to determine the hearing status of an individual with \line \up0 \e
xpndtw-9\charscalex100 dementia or AD. Furthermore, family members and other hea
lth care \line \up0 \expndtw-10\charscalex97 professionals who have interacted o
ften with the client may be able to \line \up0 \expndtw-10\charscalex96 provide
information about the circumstances in which hearing appears \line \up0 \expndtw
-10\charscalex97 to be most di\u8260?cult for the client. \par\pard\qj \li1286\r
i960\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 Because of possible
di\u8260?culties in cognition, communication, emo-\line \up0 \expndtw-8\charscal
ex100 tion, and behavior of clients with dementia or AD, obtaining services \lin
e \up0 \expndtw-7\charscalex100 from an audiologist with experience working
with individuals with \line \up0 \expndtw-10\charscalex94 neurogenic disorders
is highly recommended. The professional with this \line \up0 \expndtw-7\charsca
lex100 type of experience should provide the most eective and e\u8260?cient ser-\

line \up0 \expndtw-6\charscalex100 vices. In addition, he or she would be more c

apable of determining \line \up0 \expndtw-9\charscalex95 whether the client trul
y has a hearing loss or whether language compre-\line \up0 \expndtw-9\charscalex
93 hension is deteriorating because of cognitive decline. Thus an audiologist
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
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53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2905 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 128\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-250\slmult0 \par\pard\qj\li1551\ri697\sb88\sl-250\slmult
0 \up0 \expndtw-6\charscalex100 \ul0\nosupersub\cf2\f3\fs22 with a background in
neurogenic disorders will be able to complete \up0 \expndtw-9\charscalex96 a th
orough and accurate audiologic evaluation because of his or her \up0 \expndt
w-10\charscalex96 experience working with challenging populations. \par\pard\qj
\li1551\ri694\sb3\sl-259\slmult0\fi478 \up0 \expndtw-10\charscalex94 After the
formal hearing evaluation, suggestions will be made \line \up0 \expndtw-9
\charscalex93 about aural rehabilitation. Audiologists and other professionals c
an assist \line \up0 \expndtw-7\charscalex100 the client, family members, or car
egivers with the implementation of \line \up0 \expndtw-10\charscalex93 the recom
mendations. Schow and Nerbonne (2002) reviewed the use of \line \up0 \expndtw-7\
charscalex100 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3
\fs22 CARE\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs2
2 for management in aural rehabilitation. CARE incorporates \line \up0 \expndtw
-9\charscalex95 counseling, audibility and instrumental interventions, remed
iation for \line \up0 \expndtw-9\charscalex95 communication of activities, and
environmental coordination and partic-\line \up0 \expndtw-10\charscalex93 ipatio
n improvement (Schow & Nerbonne, 2002, p. 355). The audiologist \line \up0 \expn
dtw-9\charscalex97 is the rst professional who will counsel an individual with de
mentia or \line \up0 \expndtw-7\charscalex100 AD and his or her family members o
r caregivers about hearing loss. \line \up0 \expndtw-9\charscalex97 Counseling
should involve a thorough review of the audiologic test \line \up0 \expndtw
-9\charscalex94 results and address the needs of the client. Furthermore, sugges
tions or \line \up0 \expndtw-10\charscalex93 recommendations about what can be d
one to improve hearing should be \line \up0 \expndtw-9\charscalex92 discussed. Q
uestions or concerns posed by the client, family members, or \line \up0 \expndtw
-9\charscalex95 caregivers can be discussed during the counseling session. In ad
dition, \line \up0 \expndtw-10\charscalex96 counseling for individuals with deme
ntia or AD should involve a review \line \up0 \expndtw-9\charscalex92 of the pro
gression of the disease, eects of cognitive decline on language, \line \up0 \expn
dtw-9\charscalex92 and an explanation of how hearing loss can be aected by these
changes. \line \up0 \expndtw-9\charscalex93 The counseling session should assist
the client, family members, or care-\line \up0 \expndtw-9\charscalex93 givers t
o make decisions about how hearing loss can aect daily function-\line \up0 \expnd
tw-10\charscalex96 ing and to determine which amplication device, if any, would p
romote \line \up0 \expndtw-9\charscalex96 the best hearing. T|me spent counselin
g is important if the client, family \line \up0 \expndtw-9\charscalex94 members,
or caregivers are still grieving over the diagnosis of dementia, \line \up0 \ex
pndtw-9\charscalex96 continue to be in denial about the progressive nature of th
e disease, or \line \up0 \expndtw-9\charscalex95 exhibit stress over the cha

nging responsibilities in family dynamics \line \up0 \expndtw-9\charscalex94

(Tanner, 2003). Thus it appears that a large quantity of information must \line
\up0 \expndtw-10\charscalex94 be provided during counseling sessions, and it is
better when a number \line \up0 \expndtw-7\charscalex100 of professionals work
as a team to review the information about the \line \up0 \expndtw-9\charscalex10
0 diagnosis of dementia or AD and its eects on cognition and commu-\line \up0 \ex
pndtw-10\charscalex96 nication. This open interaction about dementia or AD will
be benecial \line \up0 \expndtw-10\charscalex95 to the client, family members, or
caregivers when one obtains accurate \line \up0 \expndtw-10\charscalex94 inform
ation about any type of therapeutic service. \par\pard\qj \li1551\ri694\sb1\sl-2
60\slmult0\fi478 \up0 \expndtw-10\charscalex96 The second portion of CARE involv
es audibility and instrumental \line \up0 \expndtw-10\charscalex93 interventions
(Schow & Nerbonne, 2002). If the audiologist recommends \line \up0 \expndtw-10\
charscalex94 the use of a hearing aid or aids or other external amplication devic
e
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41\slmult0\par\pard\li2582\sb201\sl-241\slmult0\fi0\tx7197 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Older Adults with Dementia or Alzheimer\ul0\
nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s Disease\tab \up0 \
expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 129\par\pard\qj \li1286\sb0\
sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw-10\ch
arscalex96 early in the diagnosis of dementia or AD, family members, health care
\line \up0 \expndtw-9\charscalex92 professionals, and the client must support t
he use of the device (Schow & \line \up0 \expndtw-10\charscalex94 Nerbonne, 2002
). A hearing aid would provide the amplication needed \line \up0 \expndtw-6\chars
calex100 by the individual with dementia or AD; however, the small size of \l
ine \up0 \expndtw-10\charscalex95 the device can be extremely problematic. A hea
ring aid or aids may be \line \up0 \expndtw-7\charscalex100 easily lost or mispl
aced by the individual with dementia or his or her \line \up0 \expndtw-10\charsc
alex96 caregivers. Elderly adults may have di\u8260?culty manually manipulating
the \line \up0 \expndtw-9\charscalex100 small device to adjust the volume or cha
nge batteries if assistance is \line \up0 \expndtw-8\charscalex100 unavailable.
In addition to the size of the device being a barrier, if the \line \up0 \expndt
w-9\charscalex94 amplication of sounds is perceived negatively when the device is
used, \line \up0 \expndtw-9\charscalex100 then the individual with dementia may
choose not to wear the device. \line \up0 \expndtw-9\charscalex100 This can occ
ur if the sounds during conversation and within the envi-\line \up0 \expndtw-9\c
harscalex95 ronment seem too loud for the client to tolerate. Although these bar
riers \line \up0 \expndtw-9\charscalex97 exist for the use of amplication devices
, a study by Allen et al. (2003) \line \up0 \expndtw-7\charscalex100 found that
patients with dementia and hearing impairment beneted \line \up0 \expndtw-6\chars
calex100 from the provision of hearing aids. In addition, both caregivers and \
line \up0 \expndtw-9\charscalex93 patients noted improvements in hearing; h
owever, no changes were \line \up0 \expndtw-8\charscalex100 found in cognit
ive function, activities of daily living, or caregiver \line \up0 \expndt
w-10\charscalex93 burden. \par\pard\qj \li1286\ri959\sb2\sl-258\slmult0\fi478 \u
p0 \expndtw-10\charscalex93 External amplication devices such as hearing aids can
assist indi-\line \up0 \expndtw-9\charscalex100 viduals by increasing the inten

sity of sounds. Some disadvantages to \line \up0 \expndtw-10\charscalex95 purcha

sing a hearing aid include cost, lack of insurance coverage, and \line \up0 \exp
ndtw-5\charscalex100 misunderstanding about the fact that the device will not wo
rk in all \line \up0 \expndtw-9\charscalex94 environments (National Institute on
Aging, 2002). Other devices such as \line \up0 \expndtw-9\charscalex94 telephon
e amplication systems, assistive listening devices, and TV and \line \up0 \expndt
w-9\charscalex95 radio listening systems are available to assist an individual w
ith hearing \line \up0 \expndtw-9\charscalex90 loss. Similarly, the use of these
systems depends on the daily activities and \line \up0 \expndtw-9\charscalex96
cognitive abilities of the individual with dementia or AD. As the disease \line
\up0 \expndtw-9\charscalex97 progresses, amplication will not always be helpful t
o the client; rather \line \up0 \expndtw-10\charscalex94 it can become bothersom
e, or devices can become too di\u8260?cult to use. \par\pard\qj \li1286\ri959\sb
1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 Finally, the remediation fo
r communication activities and environ-\line \up0 \expndtw-9\charscalex100 menta
l coordination and participation improvement portions of CARE \line \up0 \expndt
w-10\charscalex95 include practical suggestions of when and how to improve heari
ng abil-\line \up0 \expndtw0\charscalex104 ity \up0 \expndtw-10\charscalex93 (Sc
how & Nerbonne, 2002). For example, simple environmental \line \up0 \expn
dtw-9\charscalex93 changes can be incorporated into the client\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s life. By decreasing th
e \line \up0 \expndtw-10\charscalex95 noise level within the environment or decr
easing the proximity between \line \up0 \expndtw-9\charscalex92 speaker and list
ener, positive changes in hearing abilities for communica-\line \up0 \expndtw-10
\charscalex92 tion can occur. Additional management suggestions include having t
he
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
150}{\bkmkend Pg150}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2902 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 130\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-253\slmult0 \par\pard\qj\li1551\ri697\sb82\sl-253\slmult
0 \up0 \expndtw-9\charscalex95 \ul0\nosupersub\cf2\f3\fs22 conversational partn
er(s) speak clearly, interacting face-to-face with \line \up0 \expndtw-8\ch
arscalex100 conversational partners, providing concise information, simplif
ying \line \up0 \expndtw-9\charscalex96 communication as needed, providing r
epetition of information, and \line \up0 \expndtw-10\charscalex96 using mult
iple modalities for communication \up0 \expndtw-10\charscalex96 (National In
stitute on \par\pard\qj \li1551\ri695\sb2\sl-260\slmult0 \up0 \expndtw-10\chars
calex95 Aging, 2002). Multiple modalities used to enhance comprehension can \lin
e \up0 \expndtw-10\charscalex95 include additional forms of communication such a
s the use of gestures, \line \up0 \expndtw-10\charscalex93 nonverbal communicati
on, and writing (Brookshire, 2003). These simple \line \up0 \expndtw-10\charscal
ex95 suggestions can greatly improve communication with an individual with \line
\up0 \expndtw-9\charscalex94 dementia or AD who has a hearing loss. These s
uggestions are also \line \up0 \expndtw-10\charscalex95 benecial for other indi
viduals who have neurogenic disorders and can \line \up0 \expndtw-4\charscalex10
0 be incorporated into the client\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\n
osupersub\cf2\f3\fs22 s daily life to improve auditory \line \up0 \expndtw-

10\charscalex95 comprehension. No matter what devices or strategies are involved

in a \line \up0 \expndtw-9\charscalex93 client\ul0\nosupersub\cf11\f12\fs22 \u8
217?\ul0\nosupersub\cf2\f3\fs22 s aural rehabilitation, the focus of profe
ssional care should be \line \up0 \expndtw-9\charscalex98 on improving qualit
y of life. As the disease progresses in an individual \line \up0 \expndtw-7\char
scalex100 with dementia or AD, assisting the client to function to the best of h
is \line \up0 \expndtw-10\charscalex92 or her abilities is key. \par\pard\ql \li
4009\sb0\sl-276\slmult0 \par\pard\ql\li4009\sb231\sl-276\slmult0 \up0 \expndtw0\
charscalex103 \ul0\nosupersub\cf7\f8\fs24 SUMMARY \par\pard\qj \li1551\sb0\sl-25
7\slmult0 \par\pard\qj\li1551\ri694\sb3\sl-257\slmult0\fi478 \up0 \expndtw-10\ch
arscalex94 \ul0\nosupersub\cf2\f3\fs22 Dementia is a broad medical term encompas
sing dierent types of \line \up0 \expndtw-9\charscalex91 progressive degenerativ
e diseases. Of the various types of dementia, \line \up0 \expndtw-10\char
scalex95 Alzheimer\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs
22 s disease (AD) is the type identied most often. In dementia \line \up0 \expndt
w-10\charscalex96 and AD, gradual changes occur in the areas of cognition, commu
nica-\line \up0 \expndtw-9\charscalex95 tion, physical abilities, behavior, and
emotion. Because of the heteroge-\line \up0 \expndtw-7\charscalex100 neity of
individuals with dementia or AD, the length of time for \line \up0 \expn
dtw-9\charscalex100 progression through the stages of the disease and the severi
ty of the \line \up0 \expndtw-9\charscalex95 disease can vary. Although medicati
ons are available to slow the rate of \line \up0 \expndtw-8\charscalex100 progre
ssion of the disease, it is important to remember that a cure is \line \up0 \exp
ndtw-10\charscalex92 still unavailable. \par\pard\qj \li1551\ri695\sb1\sl-260\sl
mult0\fi478 \up0 \expndtw-10\charscalex96 Similar to the normal aging population
, individuals with dementia \line \up0 \expndtw-9\charscalex100 or AD can also e
xhibit hearing loss. Although similar types of hearing \line \up0 \expndtw-9\cha
rscalex96 loss may be evident in the individual with dementia or AD, the progres
-\line \up0 \expndtw-8\charscalex100 sive loss of cognitive abilities can make t
he identication of an actual \line \up0 \expndtw-8\charscalex100 hearing loss mor
e di\u8260?cult, especially if a hearing evaluation is done in \line \up0 \expnd
tw-9\charscalex100 the moderate or middle stages of the disease. Thus a team app
roach \line \up0 \expndtw-9\charscalex94 involving the client, family members, c
aregivers, and health care profes-\line \up0 \expndtw-9\charscalex94 sionals wil
l ensure the best care possible. The audiologist will determine
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
151}{\bkmkend Pg151}\par\pard\li2582\sb0\sl-241\slmult0\par\pard\li2582\sb0\sl-2
41\slmult0\par\pard\li2582\sb201\sl-241\slmult0\fi0\tx7215 \up0 \expndtw-8\chars
calex92 \ul0\nosupersub\cf5\f6\fs18 Older Adults with Dementia or Alzheimer\ul0\
nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s Disease\tab \up0 \
expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 131\par\pard\qj \li1286\sb0\
sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw-9\cha
rscalex93 whether an actual hearing loss exists, and information obtained by fam
ily \line \up0 \expndtw-9\charscalex91 members, caregivers, and other profes
sionals can assist to determine \line \up0 \expndtw-10\charscalex93 whether
language comprehension problems stem from cognitive decline \line \up0 \expndtw7\charscalex100 or from an actual hearing loss. After the audiologic evaluation,
aural \line \up0 \expndtw-8\charscalex100 rehabilitation will require the assis
tance of all team members to carry \line \up0 \expndtw-10\charscalex96 out the r

ecommendations made by the audiologist. The use of hearing \line \up0 \expndtw-1
0\charscalex95 devices and listening strategies will have to be monitored and mo
died \line \up0 \expndtw-9\charscalex100 as cognitive and communicative changes
occur in the client. Finally, \line \up0 \expndtw-5\charscalex100 professionals
working with individuals with dementia or AD should \line \up0 \expndtw-6\chars
calex100 always keep in mind that the most important goal is to improve the \lin
e \up0 \expndtw-10\charscalex95 client\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\
nosupersub\cf2\f3\fs22 s quality of life. \par\pard\ql \li3046\sb0\sl-276\slmult
0 \par\pard\ql\li3046\sb0\sl-276\slmult0 \par\pard\ql\li3046\sb36\sl-276\slmult0
\up0 \expndtw0\charscalex102 \ul0\nosupersub\cf7\f8\fs24 ACKNOWLEDGMENTS \par\p
ard\qj \li1286\ri960\sb258\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 \u
l0\nosupersub\cf2\f3\fs22 The author would like to thank Joanne Kawahigashi Oshi
ro, M.S., \up0 \expndtw-10\charscalex93 CCC-SLP, for her editing remarks an
d encouragement to complete \up0 \expndtw-9\charscalex98 this chapter. In add
ition, the author would like to thank Kenneth Pugh, \up0 \expndtw-9\charscalex98
Ph.D., CCC-Aud, for his motivating words and advice during the \up0 \e
xpndtw-10\charscalex93 writing process. \par\pard\ql \li3576\sb0\sl-276\slmult0
\par\pard\ql\li3576\sb211\sl-276\slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosu
persub\cf7\f8\fs24 REFERENCES \par\pard\ql \li1286\sb0\sl-220\slmult0 \par\pard\
ql\li1286\ri994\sb71\sl-220\slmult0\fi0\tx1525\tx1525 \up0 \expndtw-7\charscalex
96 \ul0\nosupersub\cf5\f6\fs18 Allen, N. H., Burns, A., Newton,V., Hickson, F.,
Ramsden, R., Rogers, J., et al. (2003). \line\tab \up0 \expndtw-7\charscalex92 T
he eects of improving hearing in dementia. Age and Ageing, 32, 189 ^193. \line \u
p0 \expndtw-7\charscalex96 Alzheimer\ul0\nosupersub\cf10\f11\fs18 \u8217?\ul0\no
supersub\cf5\f6\fs18 s Association. (2003). About Alzheimer\ul0\nosupersub\cf10
\f11\fs18 \u8217?\ul0\nosupersub\cf5\f6\fs18 s. Retrieved August 30, 2004, fro
m \line\tab \up0 \expndtw-8\charscalex96 http://www.alz.org/AboutAD/overview.htm
. \par\pard\li1286\sb20\sl-207\slmult0\fi0\tx3930 \up0 \expndtw-8\charscalex92 A
merican Psychiatric Association.\tab \up0 \expndtw-8\charscalex92 (1994). Dia
gnostic and statistical manual of mental\par\pard\li1286\sb12\sl-207\slmult
0\fi239 \up0 \expndtw-8\charscalex92 disorders (4th ed.).Washington, DC: Author.
\par\pard\li1286\sb12\sl-207\slmult0\fi0\tx5138 \up0 \expndtw-8\charscalex92 Ame
rican Speech-Language-Hearing Association.\tab \up0 \expndtw-8\charscalex92 (2
003). ASHA code of ethics\par\pard\li1286\sb13\sl-207\slmult0\fi239 \up0 \ex
pndtw-8\charscalex92 (revised). ASHA Supplement, 23, 13 ^15.\par\pard\qj \li1286
\ri993\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-7\charscalex90 Bayles, K. A., & T
omoeda, C. K. (1993). The Arizona Battery of Communication Disorders of \line\ta
b \up0 \expndtw-8\charscalex90 Dementia. Austin,TX: PRO-ED. \par\pard\qj \li1286
\ri994\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-7\charscalex94 Bayles, K. A., & T
omoeda, C. K. (1994). Functional Linguistic Communication Inventory. \line\tab
\up0 \expndtw-8\charscalex94 Austin,TX: PRO-ED. \par\pard\qj \li1286\ri993\sb0\s
l-220\slmult0\tx1525 \up0 \expndtw-7\charscalex90 Brookshire, R. H. (2003). Int
roduction to neurogenic communication disorders (6th ed.). St. \line\tab \up0 \
expndtw-8\charscalex90 Louis: Mosby. \par\pard\qj \li1286\ri994\sb0\sl-220\slmul
t0\tx1525 \up0 \expndtw-7\charscalex93 Dementia. (2003, March 26). Retrieved Jul
y 30, 2003, from http://www.neurologychannel. \line\tab \up0 \expndtw-8\charscal
ex93 com/dementia/.
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152}{\bkmkend Pg152}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2

53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2898 \up0 \expndtw-10\char

scalex96 \ul0\nosupersub\cf2\f3\fs22 132\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\ql \li1551\sb0\sl-210\slmult0 \par\pard\ql\li1551\ri730\sb121\sl-210\slmul
t0\tx1790\tx1790 \up0 \expndtw-7\charscalex96 Folstein, M. F., Folstein, S. E.,
& McHugh, P. R. (1975).\ul0\nosupersub\cf10\f11\fs18 \u8216?\u8216?\ul0\nosuper
sub\cf5\f6\fs18 Mini-mental state.\ul0\nosupersub\cf10\f11\fs18 \u8217?\u8217?\u
l0\nosupersub\cf5\f6\fs18 A practical \line\tab \up0 \expndtw-7\charscalex96 met
hod for grading the cognitive state of patients for the clinician. Jo
urnal of \line \tab \up0 \expndtw-8\charscalex78 Psychiatric Research, 12, 189
^198. \par\pard\ql \li1551\ri729\sb2\sl-220\slmult0\fi0\tx1790\tx1790\tx1790\tx1
790 \up0 \expndtw-5\charscalex100 Hopper, T., Bayles, K. A., & Kim, E. (2001).
Retained neuropsychological abilities \line\tab \up0 \expndtw-7\charscalex89 of
individuals with Alzheimer\ul0\nosupersub\cf10\f11\fs18 \u8217?\ul0\nosupersub\
cf5\f6\fs18 s disease. Seminar in Speech and Language, 22, 261^273. \line \up0 \
expndtw-8\charscalex100 National Institute on Aging Information Center (2002, Se
ptember). \line \up0 \expndtw-8\charscalex86 Hearing loss \up0 \expndtw-7\charsc
alex100 (National Institute on Aging Health Information AgePage). Retriev
ed \line\tab \up0 \expndtw-7\charscalex96 August 1, 2003, from http://www.nia.ni
h.gov/health/agepages/hearing.htm. \line \up0 \expndtw-7\charscalex96 Reisberg,
B., Ferris, S. H., de Leon, M. J., & Crook, T. (1982). The global deterioration
\line\tab \up0 \expndtw-7\charscalex90 scale for assessment of primary degenerat
ive dementia. American Journal of Psychiatry, \line \tab \up0 \expndtw-8\charsca
lex80 139,1136 ^1139. \par\pard\qj \li1551\ri728\sb0\sl-220\slmult0\tx1790 \up0
\expndtw-7\charscalex94 Schow, R. L, & Nerbonne, M. A. (2002). Introduction to a
udiologic rehabilitation (4th ed.). \line\tab \up0 \expndtw-8\charscalex94 Bosto
n: Allyn & Bacon. \par\pard\qj \li1551\ri727\sb0\sl-220\slmult0\tx1790 \up0 \exp
ndtw-7\charscalex85 Tanner, D. C. (2003). The psychology of neurogenic communica
tion disorders, a primer for health \line\tab \up0 \expndtw-8\charscalex85 care
professionals. Boston: Allyn & Bacon. \par\pard\ql \li1551\sb11\sl-207\slmult0 \
up0 \expndtw-7\charscalex93 Weinstein, B. E. (2000). Geriatric audiology. New Yo
rk: Thieme Medical Publishers.
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sb0\sl-368\slmult0 \par\pard\ql\li3339\sb0\sl-368\slmult0 \par\pard\ql\li3339\sb
212\sl-368\slmult0 \up0 \expndtw0\charscalex114 \ul0\nosupersub\cf28\f29\fs32 CH
APTER 6 \par\pard\ql \li1778\sb0\sl-368\slmult0 \par\pard\ql\li1778\sb324\sl-368
\slmult0 \up0 \expndtw0\charscalex87 \ul0\nosupersub\cf29\f30\fs32 Otitis Media:
Diagnosis and Management \par\pard\ql \li2735\sb0\sl-253\slmult0 \par\pard\ql\l
i2735\sb74\sl-253\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupersub\cf2\f3\f
s22 Teralandur K. Parthasarathy, Ph.D. \par\pard\qj \li1794\ri1486\sb0\sl-240\sl
mult0\tx2730 \up0 \expndtw-9\charscalex97 \ul0\nosupersub\cf6\f7\fs20 Department
of Special Education and Communication Disorders \line\tab \up0 \expndtw-9\char
scalex98 Southern Illinois University Edwardsville \par\pard\ql \li3738\sb7\sl-2
30\slmult0 \up0 \expndtw-7\charscalex100 Edwardsville, IL \par\pard\ql \li3472\s
b231\sl-253\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Gi
ta J. Malur, M.D. \par\pard\ql \li3193\ri2886\sb0\sl-240\slmult0\tx4021 \up0 \ex
pndtw-9\charscalex96 \ul0\nosupersub\cf6\f7\fs20 Pediatic Healthcare Unlimited \
line\tab \up0 \expndtw-9\charscalex97 Alton, IL \par\pard\ql \li2840\sb0\sl-240\

slmult0 \par\pard\ql\li2840\sb0\sl-240\slmult0 \par\pard\ql\li2840\sb0\sl-240\sl

mult0 \par\pard\ql\li2840\sb0\sl-240\slmult0 \par\pard\ql\li2840\ri2372\sb18\sl240\slmult0 \up0 \expndtw0\charscalex108 Definition \line \up0 \expndtw-9\charsc
alex97 Pathogenesis \par\pard\qj \li2840\ri3312\sb0\sl-240\slmult0 \up0 \expndtw
-2\charscalex100 Diagnosis and Implications \up0 \expndtw-3\charscalex100 Manage
ment \par\pard\qj \li3319\ri2108\sb0\sl-240\slmult0 \up0 \expndtw-8\charscalex10
0 DrugTreatment No Longer Automatic \up0 \expndtw-9\charscalex92 Surgical Treatm
ent \par\pard\qj \li2840\ri1976\sb0\sl-240\slmult0\fi478 \up0 \expndtw-9\charsca
lex95 Audiologic Management Considerations \up0 \expndtw-9\charscalex96 Summary
\par\pard\ql \li2840\sb9\sl-230\slmult0 \up0 \expndtw-8\charscalex100 References
\par\pard\qj \li1286\sb0\sl-262\slmult0 \par\pard\qj\li1286\sb0\sl-262\slmult0
\par\pard\qj\li1286\sb0\sl-262\slmult0 \par\pard\qj\li1286\ri959\sb38\sl-262\slm
ult0\fi478 \up0 \expndtw-6\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Otitis medi
a (OM) is a major cause of auditory dysfunction in \line \up0 \expndtw-9\charsc
alex100 preschool and early grade school children. At especially high risk are \
line \up0 \expndtw-9\charscalex97 children with Turner\ul0\nosupersub\cf11\f12\f
s22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s, Apert\ul0\nosupersub\cf11\f12\fs22 \u8
217?\ul0\nosupersub\cf2\f3\fs22 s, or Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\
ul0\nosupersub\cf2\f3\fs22 s syndromes or cleft palate/lip \line \up0 \expndtw-1
0\charscalex94 or any maxillofacial malformation and some groups of mentally ret
arded \line \up0 \expndtw-10\charscalex94 children. Between 26 and 43% of the po
pulation with mental retardation \line \up0 \expndtw-9\charscalex94 and develop
mental disabilities caused by Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\
nosupersub\cf2\f3\fs22 s syndrome have a \line \up0 \expndtw-9\charscalex96 h
igher incidence of OM than the remaining mentally retarded and \line \u
p0 \expndtw-9\charscalex94 developmentally disabled population. Early detect
ion and aggressive \par\pard\ql \li4275\sb0\sl-207\slmult0 \par\pard\ql\li4275
\sb57\sl-207\slmult0 \up0 \expndtw-8\charscalex83 \ul0\nosupersub\cf5\f6\fs18 13
3 \par\pard\qj \li3067\ri2882\sb0\sl-160\slmult0\fi65 \up0 \expndtw0\charscalex1
00 \ul0\nosupersub\cf30\f31\fs12 Aural Rehabilitation for People with Disabiliti
es \line \up0 \expndtw0\charscalex100 Copyright \up0 \expndtw-2\charscalex100 20
05, Elsevier Inc. All rights reserved.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
154}{\bkmkend Pg154}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2902 \up0 \expndtw-10\char
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\pard\qj \li1551\sb0\sl-253\slmult0 \par\pard\qj\li1551\ri694\sb82\sl-253\slmult

0 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 multidisciplinary as
sessment and management are critical to minimize \up0 \expndtw-9\charscalex93 th
e long-term adverse eects of hearing impairment on aspects of central \up0 \expnd
tw-9\charscalex95 auditory function or processing, linguistic-cognitive function
, and educa\up0 \expndtw-10\charscalex95 tional attainment. \par\pard\qj \li1551
\ri694\sb2\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex100 Few medical condi
tions are as common or as frustrating as OM. \up0 \expndtw-7\charscalex100 Becau
se it can result in impaired hearing during the critical years of \up0 \expndtw10\charscalex93 speech and language development, the increasing incidence of OM
is of \up0 \expndtw-9\charscalex95 major concern to parents, pediatricians, fami
ly physicians, and otolaryn\up0 \expndtw-8\charscalex100 gologists. Nothing abou
t it is easy: The diagnosis is challenging, the \up0 \expndtw-10\charscalex95 ra
nge of management options perplexing, and the array of medications \up0 \expndtw
-10\charscalex92 and regimens daunting. \par\pard\qj \li1551\ri695\sb0\sl-260\sl
mult0\fi478 \up0 \expndtw-5\charscalex100 OM refers to an inammation of the middl
e ear cavity without \line \up0 \expndtw-7\charscalex100 reference to etiology o
r pathogenesis. It is one of the most common \line \up0 \expndtw-9\charscalex96
conditions diagnosed by pediatricians in the United States, and its inci-\line \
up0 \expndtw-9\charscalex94 dence in children is growing (Schappert, 1992). Dire
ct and indirect costs \line \up0 \expndtw-9\charscalex96 associated with OM have
been estimated to be in the billions of dollars \line \up0 \expndtw-9\charscale
x90 per year (Stool, Berg, & Berman, 1994; Stool & Field, 1989). It occurs more
\line \up0 \expndtw-9\charscalex94 often in children than in adults, and its inc
idence seems to decrease with \line \up0 \expndtw-10\charscalex94 age (Teele, Kl
ein, & Rosner, 1989; Wright, McConnel, & Thompson). \par\pard\qj \li1551\ri695\s
b0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91 This chapter focuses on th
e denition, pathogenesis, and diagnostic \up0 \expndtw-10\charscalex96 and manage
ment options for OM, a common but complex condition of \up0 \expndtw-10\charscal
ex94 infants and children in the United States. \par\pard\ql \li3919\sb0\sl-276\
slmult0 \par\pard\ql\li3919\sb211\sl-276\slmult0 \up0 \expndtw0\charscalex106 \u
l0\nosupersub\cf7\f8\fs24 DEFINITION \par\pard\qj \li1551\ri696\sb258\sl-260\slm
ult0\fi478 \up0 \expndtw-10\charscalex91 \ul0\nosupersub\cf2\f3\fs22 Otitis medi
a is a general term that encompasses an array of disease \up0 \expndtw-9\charsca
lex87 processes (Paparella, Bluestone, & Arnold, 1985). The term acute otitis me
dia \up0 \expndtw-9\charscalex100 (AOM ) refers to an acute inammation of the mid
dle ear with a rapid \up0 \expndtw-10\charscalex95 onset of one or more symptoms
such as ear pain, ear pulling, otorrhea, \up0 \expndtw-4\charscalex100 fever, i
rritability, vomiting, and diarrhea. In patients with AOM, the \up0 \expndtw-4\c
harscalex100 tympanic membrane (TM) will eventually bulge with limited or no \u
p0 \expndtw-9\charscalex94 mobility to pneumatic otoscopy, which is indicative o
f middle ear eusion \up0 \expndtw-10\charscalex94 (MEE). Redness of the TM withou
t MEE is called myringitis and is often \up0 \expndtw-10\charscalex95 mistaken f
or AOM (Stool et al., 1994). \par\pard\qj \li1551\ri697\sb0\sl-260\slmult0\fi478
\up0 \expndtw-7\charscalex100 MEE is a uid in the middle ear space. An eusion may
be (1) \line \up0 \expndtw-10\charscalex92 mucoid (a thick, viscous, mucusl
ike liquid), \up0 \expndtw-10\charscalex77 (2) serous \up0 \expndtw-7\charscal
ex100 (a thin, watery \par\pard\ql \li1551\sb6\sl-253\slmult0 \up0 \expndtw-8\c
harscalex100 liquid), (3) purulent (a puslike liquid), or (4) a combination of a
ll three.
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41\slmult0\par\pard\li2914\sb201\sl-241\slmult0\fi0\tx7208 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Otitis Media: Diagnosis and Management\tab \
up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 135\par\pard\qj \li1286
\sb0\sl-253\slmult0 \par\pard\qj\li1286\ri961\sb55\sl-253\slmult0 \up0 \expndtw9\charscalex100 MEE can be the result of either AOM or OM with eusion (Bluestone,
\up0 \expndtw-9\charscalex94 1994; Bluestone & Klein, 1995). Approximately 70%
of all children in this \up0 \expndtw-8\charscalex100 country will have an occur
rence by age 3 years, making it the most \up0 \expndtw-10\charscalex95 common
diagnosis in the pediatrician\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersu
b\cf2\f3\fs22 s o\u8260?ce. \par\pard\qj \li1286\ri961\sb2\sl-260\slmult0\fi478
\up0 \expndtw-10\charscalex96 Otitis media with eusion (OME) is an inammation of t
he middle \line \up0 \expndtw-9\charscalex95 ear in which the acute infection ha
s resolved, but uid in the middle ear \line \up0 \expndtw-10\charscalex91 space
persists, sometimes for prolonged periods \up0 \expndtw-10\charscalex90 (Sto
ol et al., 1994). \par\pard\ql \li1286\ri961\sb0\sl-260\slmult0\tx1764 \up0 \
expndtw-9\charscalex96 Diagnosis of OME requires assessment of middle ear
function by \line \up0 \expndtw-10\charscalex92 means of pneumatic otoscopy o
r tympanometry (Stool et al., 1994). \line \tab \up0 \expndtw-10\charscalex95 Ma
ny synonymous terms are used to describe asymptomatic \line \up0 \expndtw
-10\charscalex95 eusion in the middle ear, such as serous OM, secretory OM, and n
on-\line \up0 \expndtw-10\charscalex96 suppurative OM, but the commonly acc
epted term is OME (Stool \line \up0 \expndtw-10\charscalex84 et al., 1994).
\par\pard\qj \li1286\ri961\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex8
8 The term persistent middle ear eusion refers to asymptomatic eusion \up0 \expndt
w-8\charscalex100 that persists for weeks to months or months after the onset of
AOM. \up0 \expndtw-10\charscalex95 The term chronic otitis media with eusion (C
OME) is used when MEE \up0 \expndtw-9\charscalex97 persists for 4 months or long
er after onset of AOM (Stool et al., 1994). \up0 \expndtw-10\charscalex94 Risk f
actors for COME are shown in Table 6.1. \par\pard\ql \li3459\sb0\sl-276\slmult0
\par\pard\ql\li3459\sb231\sl-276\slmult0 \up0 \expndtw-4\charscalex100 \ul0\nosu
persub\cf7\f8\fs24 PATHOGENESIS \par\pard\qj \li1286\sb0\sl-256\slmult0 \par\par
d\qj\li1286\ri960\sb5\sl-256\slmult0\fi478 \up0 \expndtw-10\charscalex93 \ul0\no
supersub\cf2\f3\fs22 The pathogenesis of OM is multifactorial (see Table 6.1), i
ncluding \up0 \expndtw-9\charscalex91 predisposing factors, host-related fact
ors, and non^host-related factors \up0 \expndtw-9\charscalex92 (Casselbrant,
Mandel, & Fall, 1999; Teele et al., 1989). An immature \up0 \expndtw-8\
charscalex100 immune system and a functionally immature eustachian tube are the
\up0 \expndtw-10\charscalex97 two most common factors related to the increased i
ncidence of OM in \up0 \expndtw-10\charscalex94 infants and young children. \par
\pard\qj \li1286\ri960\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 In
most children and infants, eustachian tube dysfunction is most \line \up0 \expn
dtw-9\charscalex97 commonly caused by viral infection of the upper respi
ratory tract. \line \up0 \expndtw-9\charscalex97 The most important function of
the eustachian tube is ventilation of the \line \up0 \expndtw-9\charscalex95 mi
ddle ear cavity. In the presence of eustachian tube dysfunction, \line
\up0 \expndtw-9\charscalex95 the trapped air in the middle cavity is abs
orbed, creating negative \line \up0 \expndtw-8\charscalex100 pressure, retract
ion of the TM, uid accumulation in the middle ear, \line \up0 \expndtw-8\charsca
lex100 and, eventually, bacterial invasion and proliferation (Daly, Hunter, &
\line \up0 \expndtw-10\charscalex89 Giebink, 1999). \par\pard\qj \li1286\ri960\s
b0\sl-260\slmult0\fi478 \up0 \expndtw-8\charscalex100 It has been well establish
ed that a high incidence (45 ^54%) of \line \up0 \expndtw-8\charscalex100 persi
stent conductive hearing impairment compared with that in the
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156}{\bkmkend Pg156}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2902 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 136\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li15
51\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult
0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard
\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb
0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\s
lmult0\par\pard\li1551\sb186\sl-207\slmult0\fi2773 \up0 \expndtw-8\charscalex96
Table 6.1\par\pard\li1551\sb72\sl-207\slmult0\fi1073 \up0 \expndtw-8\charscalex9
6 Risk Factors for Chronic Otitis Media with Effusion\par\pard\li1551\sb131\sl-2
07\slmult0\fi0\tx5863 \up0 \expndtw-8\charscalex96 Predisposing Factors
HostRelated Factors\tab \up0 \expndtw-8\charscalex96 Non^Host-Related Factors\par\pa
rd\li1551\sb78\sl-207\slmult0\fi0\tx3236\tx5863 \up0 \expndtw-8\charscalex96 Max
illofacial\tab \up0 \expndtw-8\charscalex96 Male gender\tab \up0 \expndtw-8\char
scalex96 Group day-care attendance\par\pard\li1551\sb12\sl-207\slmult0\fi179 \up
0 \expndtw-8\charscalex96 abnormalities\par\pard\li1551\sb13\sl-207\slmult0\fi0\
tx3236\tx5863 \up0 \expndtw-8\charscalex96 Eustachian tube\tab \up0 \expndtw-8\c
harscalex96 Race (Canadian, Eskimo,\tab \up0 \expndtw-8\charscalex96 Passive smo
ke exposure\par\pard\li1551\sb12\sl-207\slmult0\fi179\tx3415 \up0 \expndtw-8\cha
rscalex96 dysfunction\tab \up0 \expndtw-8\charscalex96 or Native American )\par\
pard\li1551\sb12\sl-207\slmult0\fi0\tx3236 \up0 \expndtw-8\charscalex96 Immunolo
gic\tab \up0 \expndtw-8\charscalex96 Sibling history or recurrent AOM
Bottle
feeding\par\pard\ql \li1730\sb3\sl-207\slmult0 \up0 \expndtw-8\charscalex90 defi
ciencies \par\pard\li3236\sb22\sl-207\slmult0\fi0\tx5863 \up0 \expndtw-8\charsca
lex90 Early onset (before age 2 years)\tab \up0 \expndtw-8\charscalex90 Use of p
acifier\par\pard\ql \li3415\sb4\sl-207\slmult0 \up0 \expndtw-8\charscalex93 of f
irst occurrence \par\pard\qj \li5863\ri762\sb3\sl-220\slmult0 \up0 \expndtw-8\ch
arscalex95 Socioeconomic conditions \up0 \expndtw-8\charscalex89 Genetics \par\p
ard\qj \li1551\ri744\sb177\sl-200\slmult0 \up0 \expndtw-6\charscalex96 \ul0\nosu
persub\cf3\f4\fs16 From Parthasarathy, T. K., Bhat,V., & Malur, G. J. (2003). Ot
itis media: A primer on diagnosis and \up0 \expndtw-6\charscalex95 management. T
he Hearing Journal, 56(6): 42^ 48. (Reprinted with permission from The Heari
ng \up0 \expndtw-7\charscalex95 Journal and Lippincott W|lliams & W|lkins.)
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
157}{\bkmkend Pg157}\par\pard\li2914\sb0\sl-241\slmult0\par\pard\li2914\sb0\sl-2
41\slmult0\par\pard\li2914\sb201\sl-241\slmult0\fi0\tx7213 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Otitis Media: Diagnosis and Management\tab \
up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 137\par\pard\qj \li1286
\sb0\sl-253\slmult0 \par\pard\qj\li1286\ri961\sb55\sl-253\slmult0 \up0 \expndtw9\charscalex96 general population is seen in children with Turner\ul0\nosupersub
\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s, Apert\ul0\nosupersub\cf11\f
12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s, or Down\ul0\nosupersub\cf11\f12\fs
22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s \up0 \expndtw-9\charscalex97 syndrome,
cleft palate/lip, any maxillofacial malformation, or some \up0 \expndtw-9\
charscalex91 groups of mentally retarded children because of clear anatomic diere
nces \up0 \expndtw-10\charscalex91 in the head and neck region. \par\pard\qj \li
1286\ri959\sb2\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 Whereas viruse
s typically are present before AOM and commonly \line \up0 \expndtw-9\charscalex
93 exist as copathogens, they are the sole pathogen in only in a small
\line \up0 \expndtw-10\charscalex86 percentage \up0 \expndtw-10\charscalex91 (6
^7%) of children with AOM. Streptococcus pneumoniae \line \up0 \expndtw-1
0\charscalex92 is the most common pathogen, followed by Haemophilus inuen
zae \line \up0 \expndtw-9\charscalex92 and Moraxella catarrhalis (Bluestone, St
ephenson, & Martin, 1992). Thus \line \up0 \expndtw-9\charscalex95 the isolation
of a specic pathogen may assist in the use of appropriate \line \up0 \expndtw-9\
charscalex96 antibiotics to treat the AOM. Spontaneous resolution of AOM
and \line \up0 \expndtw-9\charscalex97 OME occurs in 80 ^90% of all pati
ents within 3 months of onset \line \up0 \expndtw-10\charscalex88 (Stool et
al., 1994). \par\pard\ql \li2465\sb0\sl-276\slmult0 \par\pard\ql\li2465\sb231\s
l-276\slmult0 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 DIAGNOSIS
AND IMPLICATIONS \par\pard\qj \li1286\sb0\sl-257\slmult0 \par\pard\qj\li1286\ri
960\sb3\sl-257\slmult0\fi478 \up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f

3\fs22 Accurate diagnosis of AOM is critical for appropriate treatment and \line
\up0 \expndtw-7\charscalex100 follow-up. However, accurate diagnosis is often d
i\u8260?cult in infants and \line \up0 \expndtw-9\charscalex95 young children.
Symptoms of AOM are less apparent or absent or, \line \up0 \expndtw-9\cha
rscalex95 most often, overlap with those of upper respiratory tract infe
ctions. \line \up0 \expndtw-9\charscalex95 Additional challenges include lack
of patient cooperation, excessive \line \up0 \expndtw-9\charscalex96 cerume
n in the external auditory canal, and stenosis of the external \line \up0
\expndtw-9\charscalex93 auditory canal. Inexperience in the removal of cerumen a
nd in pneumatic \line \up0 \expndtw-9\charscalex91 otoscopy also contributes to
inaccurate diagnoses (Hoberman, Paradise, & \line \up0 \expndtw-10\charscalex86
Wald, 1997). \par\pard\qj \li1286\ri961\sb1\sl-260\slmult0\fi478 \up0 \expndtw-1
0\charscalex93 Pneumatic otoscopy is a simple and inexpensive procedure
to \up0 \expndtw-9\charscalex94 evaluate the status of the TM for contour
(normal, retracted, full, or \up0 \expndtw-9\charscalex90 bulging), color (ye
llow, gray, pink, amber, red, white, or blue), translucency, \up0 \expndtw-9\cha
rscalex96 and mobility. In questionable instances, results can be veried
by \up0 \expndtw-10\charscalex95 performing tympanometry, which has higher spec
icity than pneumatic \up0 \expndtw-10\charscalex94 otoscopy in detecting OME (Dal
y et al., 1999). \par\pard\qj \li1286\ri959\sb0\sl-260\slmult0\fi478 \up0 \expnd
tw-10\charscalex96 Tympanocentesis, which involves puncturing the TM and aspira\
up0 \expndtw-9\charscalex95 ting middle ear uid to permit the identication
of pathogens, has \up0 \expndtw-9\charscalex96 greater clinical signicance i
n selection of the optimal antimicrobial \up0 \expndtw-9\charscalex94 thera
py (Hoberman et al., 1997). Diagnostic tympanocentesis is strongly \up0 \expndtw
-6\charscalex100 indicated when symptoms of AOM fail to resolve after the rst an
d \up0 \expndtw-10\charscalex91 second courses of antibiotic treatment.
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scalex96 \ul0\nosupersub\cf2\f3\fs22 138\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-264\slmult0 \par\pard\qj\li1551\ri695\sb62\sl-264\slmult
0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 For many years
, numerous antibiotics were available for treatment \up0 \expndtw-9\charscalex94
of middle ear infections, and all appeared to be relatively eective. \
up0 \expndtw-9\charscalex95 However, in the past decade, the emergence of resist
ance to antibiotics \up0 \expndtw-9\charscalex100 among the common otitic pa
thogens and increased incidence of \up0 \expndtw-10\charscalex96 recurrent A
OM in infants in day care have complicated the selection of \up0 \expndtw-10\cha
rscalex92 antimicrobial therapy (Hoberman et al., 1997). \par\pard\qj \li1551\ri
695\sb0\sl-264\slmult0\fi478 \up0 \expndtw-10\charscalex96 In 1994, a task force
including the Agency for Health Care Policy \line \up0 \expndtw-10\charscalex97
and Research (AHCPR) (Stool et al., 1994), in collaboration with the \line \u
p0 \expndtw-9\charscalex100 American Academy of Pediatrics, the Americ
an Academy of \line \up0 \expndtw-10\charscalex94 Physicians, and the Amer
ican Academy of Otolaryngology, prepared \line \up0 \expndtw-8\charscalex100
specic guidelines for the management of OME in children between \line \up0 \expnd
tw-9\charscalex95 age 1 and 3 years (Stool et al., 1994). The task force pane

l concluded \line \up0 \expndtw-8\charscalex100 that when OME is suspected, pneu

matic otoscopy or tympanometry \line \up0 \expndtw-9\charscalex100 should be p
erformed to conrm the presence of eusion and to \line \up0 \expndtw-8\char
scalex100 determine TM mobility. After conrmation of OME, parental counsel-\line
\up0 \expndtw-10\charscalex95 ing and education about the risk factors li
sted in Table \up0 \expndtw-10\charscalex88 6.1 should \par\pard\qj \li1551\ri
695\sb0\sl-260\slmult0 \up0 \expndtw-9\charscalex95 be provided, and the chi
ld should be reexamined in 6 weeks. The \line \up0 \expndtw-9\charscalex10
0 AHCPR algorithm (Figs. 6.1 and 6.2) is recommended for managing \line \up0 \
expndtw-9\charscalex100 OME in an otherwise healthy child between age 1
and \up0 \expndtw-10\charscalex88 3 \up0 \expndtw-10\charscalex83 years \par\pa
rd\ql \li1551\sb3\sl-253\slmult0 \up0 \expndtw-10\charscalex91 (Stool et al., 19
94). \par\pard\qj \li1551\ri696\sb0\sl-263\slmult0\fi478 \up0 \expndtw-10\charsc
alex96 The AHCPR guideline provides an excellent, comprehensive \up0 \expn
dtw-9\charscalex97 review of the scientic literature on OME. It has, how
ever, been \up0 \expndtw-7\charscalex100 criticized for being narrow in scope,
favoring medical as opposed to \up0 \expndtw-10\charscalex93 surgical managemen
t of OME. Thus children between age 1 and 3 \up0 \expndtw-10\charscalex9
6 years who are at risk for experiencing recurrent AOM (see Table 6.1) \up0 \e
xpndtw-9\charscalex95 may require more aggressive medical or surgica
l management \up0 \expndtw-10\charscalex95 (Bluestone & Klein, 1995). \par\par
d\qj \li1551\ri697\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 Most c
ases of OME are associated with a transient conductive \line \up0 \expndtw10\charscalex91 hearing loss averaging about \up0 \expndtw-10\charscalex96 25
dB hearing level (HL) (Roseneld \par\pard\ql \li1551\sb25\sl-253\slmult0\tx
2177\tx5592 \up0 \expndtw-10\charscalex92 et al., \tab \up0 \expndtw-10\charsca
lex94 1994). The amount and viscosity of \tab \up0 \expndtw-9\charscalex100 u
id in the middle ear \par\pard\ql \li1551\sb7\sl-253\slmult0\tx6865 \up0 \ex
pndtw-10\charscalex94 determine the degree and conguration of hearing loss
\tab \up0 \expndtw-10\charscalex96 (Gravel & \par\pard\qj \li1551\ri695\sb0\sl
-264\slmult0\tx2077 \up0 \expndtw-10\charscalex97 Ellis, \tab \up0 \expndtw-10\c
harscalex92 1995; Gravel & Wallace, 2000). In some children, there is
an \line\up0 \expndtw-9\charscalex94 increased risk of a permanent high-fre
quency sensorineural hearing \line \up0 \expndtw-9\charscalex97 loss (Hunter e
t al., 1996). The mild, recurrent hearing loss, rather than \up0 \expndtw-9\char
scalex100 OME, seems to have an adverse eect on aspects of central auditory \up0
\expndtw-9\charscalex95 function or processing, linguistic-cognitive functio
n, and educational \up0 \expndtw-10\charscalex91 attainment (Gravel & Wallace,
1992, 1995).
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41\slmult0\par\pard\li2914\sb201\sl-241\slmult0\fi0\tx7206 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Otitis Media: Diagnosis and Management\tab \
up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 139\par\pard\li1615\sb0
\sl-184\slmult0\par\pard\li1615\sb0\sl-184\slmult0\par\pard\li1615\sb0\sl-184\sl
mult0\par\pard\li1615\sb0\sl-184\slmult0\par\pard\li1615\sb0\sl-184\slmult0\par\
pard\li1615\sb0\sl-184\slmult0\par\pard\li1615\sb0\sl-184\slmult0\par\pard\li161
5\sb0\sl-184\slmult0\par\pard\li1615\sb0\sl-184\slmult0\par\pard\li1615\sb0\sl-1
84\slmult0\par\pard\li1615\sb0\sl-184\slmult0\par\pard\li1615\sb0\sl-184\slmult0

\par\pard\li1615\sb28\sl-184\slmult0\fi0 \up0 \expndtw-3\charscalex100 \ul0\nosu

persub\cf38\f39\fs16 Office visit:\par\pard\li1615\sb2\sl-184\slmult0\fi0 \up0 \
expndtw-3\charscalex100 OME suspected in\par\pard\li1615\sb0\sl-184\slmult0\fi0\
tx3690\tx5753 \up0 \expndtw-3\charscalex100 presence of\tab \up0 \expndtw-3\char
scalex100 Pneumatic otoscopy\tab \up0 \expndtw-3\charscalex100 Is OME diagnosis\
par\pard\li1615\sb1\sl-184\slmult0\fi0\tx5797 \up0 \expndtw-3\charscalex100 .
Behavioral changes\tab \up0 \expndtw-3\charscalex100 certain?\par\pard\li1615\sb
1\sl-184\slmult0\fi0 \up0 \expndtw-3\charscalex100 . Ear pain or discomfort\pa
r\pard\li1615\sb0\sl-184\slmult0\fi0 \up0 \expndtw-3\charscalex100 . Hearing l
oss\par\pard\li2503\sb0\sl-184\slmult0\par\pard\li2503\sb0\sl-184\slmult0\par\pa
rd\li2503\sb136\sl-184\slmult0\fi3856 \up0 \expndtw-2\charscalex100 \ul0\nosuper
sub\cf37\f38\fs16 NO\par\pard\li2503\sb1\sl-184\slmult0\fi0 \up0 \expndtw-2\char
scalex100 YES\par\pard\li3933\sb184\sl-184\slmult0\fi0\tx5878 \up0 \expndtw-2\ch
arscalex100 \ul0\nosupersub\cf38\f39\fs16 Flat (<0.2 mmhos)\tab \up0 \expndtw-2\
charscalex100 Tympanometry\par\pard\ql \li5878\sb0\sl-184\slmult0 \par\pard\ql\l
i5878\sb176\sl-184\slmult0 \up0 \expndtw-2\charscalex100 Normal compliance \par\
pard\li1759\sb0\sl-184\slmult0\par\pard\li1759\sb0\sl-184\slmult0\par\pard\li175
9\sb0\sl-184\slmult0\par\pard\li1759\sb107\sl-184\slmult0\fi236\tx6162 \up0 \exp
ndtw-2\charscalex100 Observe\tab \up0 \expndtw-2\charscalex100 Not OME\par\pard\
li1759\sb1\sl-184\slmult0\fi491\tx4006 \up0 \expndtw-2\charscalex100 or\tab \up0
\expndtw-2\charscalex100 Counseling\par\pard\li1759\sb1\sl-184\slmult0\fi0\tx32
03\tx4137\tx6033 \up0 \expndtw-2\charscalex100 Oral antibiotics\tab \dn3 \expndt
w-2\charscalex100 and\tab \up0 \expndtw-2\charscalex100 for risk\tab \up0 \expnd
tw-2\charscalex100 Do individual\par\pard\li1621\sb3\sl-184\slmult0\fi2340\tx625
8 \dn2 \expndtw-2\charscalex100 factor control\tab \up0 \expndtw-2\charscalex100
patient\par\pard\li1621\sb0\sl-183\slmult0\fi0\tx6062 \up0 \expndtw-2\charscale
x100 Return office visit in\tab \up0 \expndtw-2\charscalex100 management\par\par
d\ql \li2005\sb0\sl-176\slmult0 \up0 \expndtw-2\charscalex100 6 weeks \par\pard\
qj \li1286\ri992\sb128\sl-220\slmult0\fi0\tx2249 \up0 \expndtw-7\charscalex100 \
ul0\nosupersub\cf5\f6\fs18 Figure 6.1 \tab \up0 \expndtw-5\charscalex100 Agency
for Health Care Policy and Research algorithm for managing \line\up0 \expndtw-6
\charscalex100 otitis media with eusion (OME). (From Parthasarathy, T. K., Bhat,
V., & Malur, G. J. \line \up0 \expndtw-7\charscalex93 [2003]. Otitis media: A pr
imer on diagnosis and management.The Hearing Journal, 56[6]: \line \up0 \expndtw
-7\charscalex97 42^ 48. Reprinted with permission fromThe Hearing Journal and Li
ppincott W|lliams & \line \up0 \expndtw-8\charscalex97 W|lkins.)
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{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
160}{\bkmkend Pg160}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2903 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 140\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\sect\sectd\sbknone\cols2\colno1\colw5645\colsr40\colno2\colw2875\colsr160\
ql \li1804\sb0\sl-184\slmult0 \par\pard\ql \li1804\sb0\sl-184\slmult0 \par\pard\
ql \li1804\sb0\sl-184\slmult0 \par\pard\ql \li1804\sb0\sl-184\slmult0 \par\pard\
ql \li1804\sb0\sl-184\slmult0 \par\pard\ql \li1804\sb0\sl-184\slmult0 \par\pard\
ql \li1804\sb0\sl-184\slmult0 \par\pard\ql \li1804\sb0\sl-184\slmult0 \par\pard\
ql \li1804\sb0\sl-184\slmult0 \par\pard\ql \li1804\sb0\sl-184\slmult0 \par\pard\
ql \li1804\sb0\sl-184\slmult0 \par\pard\ql \li1804\sb0\sl-184\slmult0 \par\pard\

ql \li1867\sb144\sl-184\slmult0\tx3362\tx4604 \up0 \expndtw-2\charscalex100 \ul0

\nosupersub\cf39\f40\fs16 OME\tab \up0 \expndtw-2\charscalex100 Observe\tab \up0
\expndtw-2\charscalex100 Continue\par\pard\ql \li1804\sb34\sl-144\slmult0\tx354
4\tx4298 \up0 \expndtw-2\charscalex100 persists\tab \up0 \expndtw-2\charscalex10
0 or\tab \up0 \expndtw-2\charscalex100 counseling for risk\par\pard\ql \li1838\s
b40\sl-144\slmult0\tx3102\tx4465 \up0 \expndtw-2\charscalex100 after 6\tab \up0
\expndtw-2\charscalex100 oral antibiotics\tab \up0 \expndtw-2\charscalex100 fact
or control\par\pard\ql \li1844\sb40\sl-146\slmult0 \up0 \expndtw-2\charscalex100
weeks\par\pard\ql \li2693\sb0\sl-184\slmult0 \par\pard\ql \li2693\sb0\sl-184\sl
mult0 \par\pard\ql \li2693\sb0\sl-184\slmult0 \par\pard\ql \li2693\sb65\sl-184\s
lmult0 \up0 \expndtw-2\charscalex100 <20 dB HL in both ears\par\pard\ql \li1727\
sb0\sl-184\slmult0 \par\pard\ql \li1727\sb0\sl-184\slmult0 \par\pard\ql \li1727\
sb0\sl-184\slmult0 \par\pard\ql \li1727\sb90\sl-184\slmult0\tx3801 \up0 \expndtw
-2\charscalex100 OME persists\tab \up0 \expndtw-2\charscalex100 Hearing\par\pard
\ql \li1703\sb2\sl-184\slmult0\tx3712 \up0 \expndtw-2\charscalex100 after 3 mont
hs\tab \up0 \expndtw-2\charscalex100 evaluation\par\pard\ql \li1703\sb0\sl-184\s
lmult0 \par\pard\ql \li1703\sb0\sl-184\slmult0 \par\pard\ql \li1703\sb0\sl-184\s
lmult0 \par\pard\ql \li1703\sb0\sl-184\slmult0 \par\pard\ql \li1727\sb25\sl-184\
slmult0 \up0 \expndtw-2\charscalex100 OME persists\par\pard\ql \li1703\sb2\sl-18
4\slmult0 \up0 \expndtw-2\charscalex100 after 4 months\par\pard\column \ql \li59
23\sb0\sl-184\slmult0 \par\pard\ql \li5923\sb0\sl-184\slmult0 \par\pard\ql \li59
23\sb0\sl-184\slmult0 \par\pard\ql \li5923\sb0\sl-184\slmult0 \par\pard\ql \li59
23\sb0\sl-184\slmult0 \par\pard\ql \li5923\sb0\sl-184\slmult0 \par\pard\ql \li59
23\sb0\sl-184\slmult0 \par\pard\ql \li5923\sb0\sl-184\slmult0 \par\pard\ql \li59
23\sb0\sl-184\slmult0 \par\pard\ql \li5923\sb0\sl-184\slmult0 \par\pard\ql \li59
23\sb0\sl-184\slmult0 \par\pard\ql \li5923\sb0\sl-184\slmult0 \par\pard\ql \li34
7\sb184\sl-184\slmult0 \up0 \expndtw-2\charscalex100 Hearing\par\pard\ql \li258\
sb1\sl-183\slmult0 \up0 \expndtw-2\charscalex100 evaluation\par\pard\ql \li347\s
b1\sl-183\slmult0 \up0 \expndtw-2\charscalex100 (option)\par\pard\ql \li5685\sb0
\sl-184\slmult0 \par\pard\ql \li5685\sb0\sl-184\slmult0 \par\pard\ql \li5685\sb0
\sl-184\slmult0 \par\pard\ql \li5685\sb0\sl-184\slmult0 \par\pard\ql \li5685\sb0
\sl-184\slmult0 \par\pard\ql \li5685\sb0\sl-184\slmult0 \par\pard\ql \li5685\sb0
\sl-184\slmult0 \par\pard\ql \li5685\sb0\sl-184\slmult0 \par\pard\ql \li5685\sb0
\sl-184\slmult0 \par\pard\ql \li20\sb23\sl-184\slmult0 \up0 \expndtw-2\charscale
x100 \ul0\nosupersub\cf40\f41\fs16 \u8805?\ul0\nosupersub\cf39\f40\fs16 20 dB H
L \par\pard\sect\sectd\sbknone \ql \li4677\sb6\sl-184\slmult0 \up0 \expndtw-2\ch
arscalex100 Bilateral myringotomy with tube placement \par\pard\ql \li4677\sb176
\sl-184\slmult0 \up0 \expndtw-2\charscalex100 Continue counseling for risk facto
r control \par\pard\qj \li1551\ri727\sb187\sl-220\slmult0\fi0\tx2534 \up0 \expnd
tw-7\charscalex100 \ul0\nosupersub\cf5\f6\fs18 Figure 6.2 \tab \up0 \expndtw-5\
charscalex100 Agency for Health Care Policy and Research algorithm for managing
\line\up0 \expndtw-6\charscalex100 persistent otitis media with eusion (OME). (
From Parthasarathy, T. K., Bhat, V., & \line \up0 \expndtw-7\charscalex96 Malur,
G. J. [2003]. Otitis media: A primer on diagnosis and management. The Hearing \
up0 \expndtw-7\charscalex93 Journal, 56[6]: 42^ 48. Reprinted with permission fr
omThe Hearing Journal and Lippincott \up0 \expndtw-8\charscalex93 W|lliams & W|l
kins.)
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{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft3033\shptop4329\shpright4230\shpbottom4349\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz45\shplid9
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1197}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(1197,20);(1197,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft4230\shptop3329\shpright4250\shpbottom4335\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz47\shplid10
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 20}}{\sp{\sn geoBottom}{\sv 1006}}
{\sp{\sn pVerticies}{\sv 8;4;(0,1006);(20,1006);(20,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp {\*\shpinst\shpleft4236\shptop4329\shpright5667\shpbottom4349\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz49\shplid11
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1431}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(1431,20);(1431,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft5667\shptop3329\shpright5687\shpbottom4335\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz51\shplid12
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 20}}{\sp{\sn geoBottom}{\sv 1006}}
{\sp{\sn pVerticies}{\sv 8;4;(0,1006);(20,1006);(20,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft5673\shptop4329\shpright6865\shpbottom4349\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz53\shplid13
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1192}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(1192,20);(1192,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6865\shptop3329\shpright6885\shpbottom4335\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz55\shplid14
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 20}}{\sp{\sn geoBottom}{\sv 1006}}
{\sp{\sn pVerticies}{\sv 8;4;(0,1006);(20,1006);(20,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6865\shptop4329\shpright6871\shpbottom4335\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz57\shplid15
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6}}{\sp{\sn geoBottom}{\sv 6}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(6,0);(6,6);(0,6)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp {\*\shpinst\shpleft1599\shptop3371\shpright2557\shpbottom4329\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz65\shplid16
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 958}}{\sp{\sn geoBottom}{\sv 958}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(958,0);(958,958);(0,958)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
15}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1601\shptop3371\shpright2557\shpbottom4329\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz78\shplid17
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 956}}{\sp{\sn geoBottom}{\sv 958}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(0,958);(956,958);(956,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft1599\shptop4329\shpright1599\shpbottom3371\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz78\shplid18{\sp{\sn shapeType}{\
sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\s
n lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft3634\shptop4329\shpright3634\shpbottom4568\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz110\shplid19{\sp{\sn shapeType}{
\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\
sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft4952\shptop4329\shpright4952\shpbottom4568\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz110\shplid20{\sp{\sn shapeType}{
\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\
sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft6269\shptop4329\shpright6269\shpbottom4568\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz110\shplid21{\sp{\sn shapeType}{
\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\
sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft3634\shptop4568\shpright6269\shpbottom4568\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz110\shplid22{\sp{\sn shapeType}{
\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\
sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft4455\shptop4568\shpright4952\shpbottom4927\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz110\shplid23
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 497}}{\sp{\sn geoBottom}{\sv 359}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;3;(497,0);(497,359);(0,359)}}
{\sp{\sn pSegmentInfo}{\sv 2;7;16384;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft4353\shptop4875\shpright4457\shpbottom4980\shpfhdr0\shp

bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz115\shplid24
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 104}}{\sp{\sn geoBottom}{\sv 105}}
{\sp{\sn pVerticies}{\sv 8;4;(104,0);(0,53);(104,105);(104,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1599\shptop5526\shpright2796\shpbottom6125\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz118\shplid25
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1197}}{\sp{\sn geoBottom}{\sv 599}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(1197,0);(1197,599);(0,599)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
15}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1601\shptop5526\shpright2796\shpbottom6125\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz125\shplid26
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1195}}{\sp{\sn geoBottom}{\sv 599}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(0,599);(1195,599);(1195,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft1599\shptop6125\shpright1599\shpbottom5526\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz125\shplid27{\sp{\sn shapeType}{
\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\
sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft3515\shptop5526\shpright4712\shpbottom6125\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz137\shplid28
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1197}}{\sp{\sn geoBottom}{\sv 599}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(1197,0);(1197,599);(0,599)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
15}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft3515\shptop5526\shpright4712\shpbottom6125\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz140\shplid29
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1197}}{\sp{\sn geoBottom}{\sv 599}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(0,599);(1197,599);(1197,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}

}}
{\shp {\*\shpinst\shpleft3515\shptop6125\shpright3515\shpbottom5526\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz140\shplid30{\sp{\sn shapeType}{
\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\
sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft5551\shptop5526\shpright6628\shpbottom6125\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz151\shplid31
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1077}}{\sp{\sn geoBottom}{\sv 599}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(1077,0);(1077,599);(0,599)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
15}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft5550\shptop5526\shpright6628\shpbottom6125\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz153\shplid32
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1078}}{\sp{\sn geoBottom}{\sv 599}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(0,599);(1078,599);(1078,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft5550\shptop6125\shpright5550\shpbottom5526\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz153\shplid33{\sp{\sn shapeType}{
\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\
sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft1599\shptop6724\shpright2796\shpbottom7323\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz165\shplid34
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1197}}{\sp{\sn geoBottom}{\sv 599}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(1197,0);(1197,599);(0,599)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
15}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1601\shptop6724\shpright2796\shpbottom7323\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz171\shplid35
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1195}}{\sp{\sn geoBottom}{\sv 599}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(0,599);(1195,599);(1195,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft1599\shptop7323\shpright1599\shpbottom6724\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz171\shplid36{\sp{\sn shapeType}{
\sv 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\

sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft4593\shptop7083\shpright7729\shpbottom7802\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz187\shplid37
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 3136}}{\sp{\sn geoBottom}{\sv 719}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(3136,0);(3136,719);(0,719)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
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1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft4593\shptop7083\shpright7730\shpbottom7802\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz189\shplid38
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 3137}}{\sp{\sn geoBottom}{\sv 719}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;4;(0,719);(3137,719);(3137,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft4593\shptop7802\shpright4593\shpbottom7083\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz189\shplid39{\sp{\sn shapeType}{
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sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft2796\shptop5047\shpright2399\shpbottom5345\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz203\shplid40{\sp{\sn shapeType}{
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sn lineWidth}{\sv 14241}}
}}
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41\slmult0\par\pard\li2914\sb201\sl-241\slmult0\fi0\tx7210 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Otitis Media: Diagnosis and Management\tab \
up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 141\par\pard\li1286\sb0
\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\sl
mult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\
pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li128
6\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-2
07\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0
\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\
li1286\sb39\sl-207\slmult0\fi2770 \up0 \expndtw-8\charscalex97 \ul0\nosupersub\c
f5\f6\fs18 Table 6.2\par\pard\li1286\sb71\sl-207\slmult0\fi268 \up0 \expndtw-8\c
harscalex97 Medical Complications of Untreated Chronic Otitis Media with Effusio
n\par\pard\li1286\sb131\sl-207\slmult0\fi0\tx5163 \up0 \expndtw-8\charscalex97 I
ntracranial\tab \up0 \expndtw-8\charscalex97 Extracranial\par\pard\li1286\sb80\s
l-207\slmult0\fi0\tx5162 \up0 \expndtw-8\charscalex97 Abscess\tab \up0 \expndtw8\charscalex97 Tympanic membrane perforation\par\pard\li1286\sb12\sl-207\slmult0
\fi180\tx5162 \up0 \expndtw-8\charscalex97 Extradural\tab \up0 \expndtw-8\charsc
alex97 Cholesteatoma\par\pard\li1286\sb12\sl-207\slmult0\fi180\tx5162 \up0 \expn
dtw-8\charscalex97 Subdural\tab \up0 \expndtw-8\charscalex97 Mastoiditis\par\par
d\li1286\sb13\sl-207\slmult0\fi180\tx5162 \up0 \expndtw-8\charscalex97 Brain\tab
\up0 \expndtw-8\charscalex97 Tympanosclerosis\par\pard\li1286\sb12\sl-207\slmul
t0\fi0\tx5162 \up0 \expndtw-8\charscalex97 Meningitis\tab \up0 \expndtw-8\charsc
alex97 Ossicular discontinuity\par\pard\li1286\sb11\sl-207\slmult0\fi0\tx5162 \u
p0 \expndtw-8\charscalex97 Lateral sinus thrombosis\tab \up0 \expndtw-8\charscal
ex97 Facial paralysis\par\pard\li1286\sb12\sl-207\slmult0\fi0\tx5163 \up0 \expnd
tw-8\charscalex97 Otic hydrocephalus\tab \up0 \expndtw-8\charscalex97 Labyrinthi
tis\par\pard\ql \li5163\sb5\sl-207\slmult0 \up0 \expndtw-7\charscalex100 Hearing
impairment \par\pard\qj \li5342\ri1136\sb3\sl-220\slmult0 \up0 \expndtw-8\chars
calex97 Conductive (most common) \line \up0 \expndtw-8\charscalex98 Mixed \par\p

ard\ql \li5342\sb11\sl-207\slmult0 \up0 \expndtw-8\charscalex91 Sensorineural \p

ar\pard\qj \li1286\ri1009\sb179\sl-200\slmult0 \up0 \expndtw-6\charscalex96 \ul0
\nosupersub\cf3\f4\fs16 From Parthasarathy,T. K., Bhat,V., & Malur, G. J. (2003)
. Otitis media: A primer on diagnosis and \up0 \expndtw-6\charscalex91 managemen
t.The Hearing Journal, 56(6): 42^ 48. (Reprinted with permission fromThe Hearing
Journal \up0 \expndtw-7\charscalex91 and Lippincott W|lliams & W|lkins.)
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1551\ri694\sb238\sl-260\slmult0\fi478 \up0 \expndtw-5\charscalex100 \ul0\nosuper

sub\cf2\f3\fs22 Medical treatment is the rst line of defense for children with \
up0 \expndtw-9\charscalex96 OME. Currently, with use of antibiotics, some of the
potential complica\up0 \expndtw-10\charscalex96 tions of untreated OME (Table 6
.2) are uncommon. \par\pard\qj \li1551\ri695\sb0\sl-260\slmult0\fi478 \up0 \expn
dtw-6\charscalex100 Most children with AOM are treated with an antimicro
bial \up0 \expndtw-9\charscalex95 agent (Table 6.3). All such medications have
approximately equivalent \up0 \expndtw-7\charscalex100 clinical e\u8260?cacy, a
lthough there are signicant dierences in their cost, \up0 \expndtw-10\charscalex91
side eects, and palatability. \par\pard\ql \li2030\sb6\sl-253\slmult0\tx3525\tx4
241\tx6565 \up0 \expndtw-3\charscalex100 Amoxicillin at \tab \up0 \expndtw-10\c
harscalex82 40 ^ 60 \tab \up0 \expndtw-9\charscalex100 mg/kg/day remains the \
tab \up0 \expndtw-10\charscalex94 rst standard \par\pard\qj \li1551\ri697\sb2\sl
-260\slmult0\fi0 \up0 \expndtw-6\charscalex100 line of treatment in most childre
n (Doern, Brueggemann, & Pierce, \up0 \expndtw-9\charscalex93 1997). This drug
is relatively safe and inexpensive, is well tolerated, \up0 \expndtw-9\
charscalex96 and is eective against the gram-positive bacteria S. pneumon
iae. \up0 \expndtw-10\charscalex95 However, two gram-negative pathogens\ul0\n
osupersub\cf41\f42\fs22
b\ul0\nosupersub\cf2\f3\fs22 -lactamase producing H
. \up0 \expndtw-9\charscalex95 inuenzae and M. catarrhalis are resistant t
o amoxicillin treatment \up0 \expndtw-10\charscalex92 (Doern et al., 1997). \p
ar\pard\qj \li1551\ri696\sb0\sl-260\slmult0\fi478 \up0 \expndtw-7\charscalex100
In children with persistent AOM or at high risk for COME \line \up0 \e
xpndtw-9\charscalex95 based on host and nonhost factors (see Table 6.1), it may
be preferable \line \up0 \expndtw-7\charscalex100 to start treatment with a drug
or combination of drugs that is eective \line \up0 \expndtw-10\charscalex90 agai
nst the three most common pathogens: S. pneumoniae, H. inuenzae, \line \up0 \expn
dtw-9\charscalex95 and M. catarrhalis (Barnett, Teele, & Klein, 1997). Such age
nts include \line \up0 \expndtw-10\charscalex95 second- and third-generation
cephalosporins \up0 \expndtw-10\charscalex84 (see Table \up0 \expndtw-10\charsc
alex95 6.3), which \par\pard\qj \li1551\ri696\sb0\sl-260\slmult0\fi0 \up0 \expn
dtw-9\charscalex94 are eective against gram-negative bacteria, including H.
inuenzae \up0 \expndtw-9\charscalex95 and M. catarrhalis. They have been
widely used for the treatment \up0 \expndtw-9\charscalex96 of upper and l
ower respiratory tract infections, sinusitis, and AOM \up0 \expndtw-10\cha
rscalex91 (Barnett et al., 1997). \par\pard\qj \li1551\ri696\sb0\sl-260\slmult0\
fi478 \up0 \expndtw-10\charscalex95 In some children, higher-than-standard d
osages of amoxicillin \up0 \expndtw-10\charscalex93 (e.g., 80 ^100 mg/kg/day)
are recommended. This approach is based on \up0 \expndtw-10\charscalex95 pharmac
okinetic studies that suggest higher dosages of amoxicillin are \up0 \expndtw-9\
charscalex91 more active against moderately and highly resistant S. pneumoniae (
Block, \up0 \expndtw-9\charscalex91 1997; McCraken, 1995). Linsk, Gilsdorf, & Le
sperance (1999) developed a \up0 \expndtw-10\charscalex96 management approach fo
r patients with a high risk of having amoxicil\up0 \expndtw-10\charscalex86 linresistant S. pneumoniae (Fig. 6.3). \par\pard\qj \li1551\ri697\sb0\sl-260\slmult
0\fi478 \up0 \expndtw-10\charscalex94 Currently, there is no consensus as to wha
t constitutes amoxicillin \line \up0 \expndtw-9\charscalex95 treatment failure.
Linsk et al. (1999) dened amoxicillin treatment failure \line \up0 \expndtw-9\cha
rscalex92 as the\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2
\f3\fs22 persistence or rapid recurrence of OM symptoms, such as otalgia, \line
\up0 \expndtw-9\charscalex92 irritability, sleeplessness, anorexia or fever,
together with physical
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b0\sl-207\slmult0 \par\pard\ql\li4056\sb0\sl-207\slmult0 \par\pard\ql\li4056\sb0
\sl-207\slmult0 \par\pard\ql\li4056\sb0\sl-207\slmult0 \par\pard\ql\li4056\sb0\s
l-207\slmult0 \par\pard\ql\li4056\sb37\sl-207\slmult0 \up0 \expndtw-8\charscalex
95 \ul0\nosupersub\cf5\f6\fs18 Table 6.3 \par\pard\ql \li1591\sb73\sl-207\slmult
0 \up0 \expndtw-1\charscalex100 Available Antimicrobial Agents for theTreatment
of Acute Otitis Media \par\pard\ql \li1286\sb133\sl-207\slmult0 \up0 \expndtw-4\
charscalex100 First-line agents \par\pard\ql \li1286\ri3184\sb3\sl-220\slmult0\t
x1466 \up0 \expndtw-8\charscalex89 Aminopenicillin \line\tab \up0 \expndtw-8\cha
rscalex90 Amoxicillin \par\pard\ql \li1286\sb131\sl-207\slmult0 \up0 \expndtw-5\
charscalex100 Second-line agents \par\pard\ql \li1286\ri2378\sb3\sl-220\slmult0\
tx1466 \up0 \expndtw-8\charscalex85 Aminopenicillin plus\ul0\nosupersub\cf35\f36
\fs18 b\ul0\nosupersub\cf5\f6\fs18 -lactamase inhibitor \line\tab \up0 \expndtw
-8\charscalex86 Amoxicillin-clavulanate \par\pard\ql \li1286\ri2610\sb120\sl-220
\slmult0\tx1466 \up0 \expndtw-8\charscalex79 Cephalosporins (second-generation)
\line\tab \up0 \expndtw-8\charscalex80 Cefaclor \par\pard\ql \li1466\sb11\sl-207
\slmult0 \up0 \expndtw-6\charscalex100 Cefprozil \par\pard\ql \li1466\ri3188\sb3
\sl-220\slmult0 \up0 \expndtw-7\charscalex100 Cefuroxime \line \up0 \expndtw-6\c
harscalex100 Cefixime \line \up0 \expndtw-8\charscalex92 Loracarbef \par\pard\ql
\li1286\ri2662\sb120\sl-220\slmult0\tx1466 \up0 \expndtw-8\charscalex82 Cephalo
sporins (third-generation) \line\tab \up0 \expndtw-8\charscalex83 Cefpodoxime \p
ar\pard\ql \li1466\sb11\sl-207\slmult0 \up0 \expndtw-4\charscalex100 Cefdinir \p
ar\pard\ql \li1466\sb1\sl-198\slmult0 \up0 \expndtw-6\charscalex100 Ceftibuten \
par\pard\ql \li1466\sb15\sl-207\slmult0 \up0 \expndtw-8\charscalex95 Ceftriaxone
(intramuscular) \par\pard\ql \li1286\sb133\sl-207\slmult0 \up0 \expndtw-8\chars
calex81 Macrolides \par\pard\ql \li1466\sb13\sl-207\slmult0 \up0 \expndtw-5\char
scalex100 Azithromycin \par\pard\ql \li1466\ri2632\sb3\sl-220\slmult0 \up0 \expn
dtw-8\charscalex97 Erythromycin-sulfisoxazole \line \up0 \expndtw-8\charscalex98
Clarithromycin \par\pard\qj \li1286\ri4249\sb120\sl-220\slmult0 \up0 \expndtw-8
\charscalex88 Trimethoprim-sulfamethoxazole (TMP-SMX) \up0 \expndtw-8\charscalex
82 Fluroquinolones \par\pard\ql \li1466\sb11\sl-207\slmult0 \up0 \expndtw-8\char
scalex97 Ofloxacin (otic drops for AOM in patients with tympanostomy tubes) \par
\pard\qj \li1286\ri1009\sb139\sl-200\slmult0 \up0 \expndtw-6\charscalex96 \ul0\n
osupersub\cf3\f4\fs16 From Parthasarathy,T. K., Bhat,V., & Malur, G. J. (2003).
Otitis media: A primer on diagnosis and \up0 \expndtw-6\charscalex91 management.
The Hearing Journal, 56(6): 42^ 48. (Reprinted with permission fromThe Hearing J
ournal \up0 \expndtw-7\charscalex91 and Lippincott W|lliams & W|lkins.)
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mult0\fi0\tx4814 \up0 \expndtw-2\charscalex100 (80-100 mg/kg/twice per day)\tab
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i2197\sb43\sl-172\slmult0\fi0\tx6069 \up0 \expndtw-2\charscalex100 \ul0\nosupers
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slmult0\fi0\tx5914 \dn3 \expndtw-2\charscalex100 clearance in 1 month\tab \up0 \
expndtw-2\charscalex100 and\par\pard\ql \li5153\sb1\sl-145\slmult0 \up0 \expndtw
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lt0 \par\pard\ql\li5940\sb0\sl-172\slmult0 \par\pard\ql\li5940\sb9\sl-172\slmult
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i5036\sb109\sl-172\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf42\f4
3\fs15 Is there a clinical improvement? \par\pard\ql \li5921\sb0\sl-172\slmult0
\par\pard\ql\li5921\sb0\sl-172\slmult0 \par\pard\ql\li5921\sb45\sl-172\slmult0 \
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77\sb109\sl-172\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf42\f43\f
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lmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf43\f44\fs15 No \par\pard\
ql \li5036\sb109\sl-172\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf
42\f43\fs15 Is there a clinical improvement? \par\pard\ql \li5940\sb0\sl-172\slm
ult0 \par\pard\ql\li5940\sb0\sl-172\slmult0 \par\pard\ql\li5940\sb45\sl-172\slmu
lt0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf43\f44\fs15 No \par\pard\ql
\li4301\sb109\sl-172\slmult0 \up0 \expndtw-2\charscalex100 \ul0\nosupersub\cf42\
f43\fs15 Tympanocentesis and specific microbial treatment \par\pard\qj \li1551\r
i729\sb189\sl-220\slmult0\tx2521 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\c
f5\f6\fs18 Figure 6.3 \tab \up0 \expndtw-5\charscalex100 Acute otitis media (AOM
) treatment approach. OME, otitis media with \line\up0 \expndtw-6\charscalex100
eusion (From Parthasarathy, T. K., Bhat, V., & Malur, G. J. [2003]. Otitis medi
a: A \line \up0 \expndtw-7\charscalex93 primer on diagnosis and management.The H
earing Journal, 56[6]: 42^ 48. Reprinted with \up0 \expndtw-8\charscalex93 permi
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}}
{\shp {\*\shpinst\shpleft5618\shptop3579\shpright5723\shpbottom3683\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(52,104);(105,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
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}}
{\shp {\*\shpinst\shpleft2317\shptop4753\shpright4113\shpbottom4873\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;3;(1796,0);(1796,120);(0,120)}}
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}}
{\shp {\*\shpinst\shpleft4113\shptop4873\shpright6149\shpbottom4873\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft2317\shptop4873\shpright2317\shpbottom5009\shpfhdr0\shp
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sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft2265\shptop5008\shpright2370\shpbottom5112\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(53,104);(105,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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}}
{\shp {\*\shpinst\shpleft6149\shptop4873\shpright6149\shpbottom5009\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft6097\shptop5008\shpright6202\shpbottom5112\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
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}}
{\shp {\*\shpinst\shpleft4952\shptop5495\shpright7107\shpbottom6333\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(2155,0);(2155,838);(0,838)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
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}}
{\shp {\*\shpinst\shpleft4952\shptop5495\shpright7107\shpbottom6333\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,838);(2155,838);(2155,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}

{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}

}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
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}}
{\shp {\*\shpinst\shpleft4952\shptop6333\shpright4952\shpbottom5495\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft1599\shptop5704\shpright3155\shpbottom6183\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(1556,0);(1556,479);(0,479)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
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}}
{\shp {\*\shpinst\shpleft1601\shptop5704\shpright3155\shpbottom6183\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,479);(1554,479);(1554,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
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}}
{\shp {\*\shpinst\shpleft1599\shptop6183\shpright1599\shpbottom5704\shpfhdr0\shp
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sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft2796\shptop4417\shpright5670\shpbottom4417\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft4952\shptop6815\shpright7227\shpbottom7174\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(2275,0);(2275,359);(0,359)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
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}}
{\shp {\*\shpinst\shpleft4952\shptop6815\shpright7227\shpbottom7174\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,359);(2275,359);(2275,0);(0,0)}}

{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}

{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
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}}
{\shp {\*\shpinst\shpleft4952\shptop7174\shpright4952\shpbottom6815\shpfhdr0\shp
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sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft4593\shptop7653\shpright7706\shpbottom8013\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(3113,0);(3113,360);(0,360)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
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}}
{\shp {\*\shpinst\shpleft4593\shptop7653\shpright7706\shpbottom8013\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,360);(3113,360);(3113,0);(0,0)}}
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}}
{\shp {\*\shpinst\shpleft4593\shptop8013\shpright4593\shpbottom7653\shpfhdr0\shp
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sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft4952\shptop8555\shpright7227\shpbottom8915\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(2275,0);(2275,360);(0,360)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
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}}
{\shp {\*\shpinst\shpleft4952\shptop8555\shpright7227\shpbottom8915\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,360);(2275,360);(2275,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14241}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}

}}
{\shp {\*\shpinst\shpleft4952\shptop8915\shpright4952\shpbottom8555\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft4233\shptop9394\shpright7706\shpbottom9753\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(3473,0);(3473,359);(0,359)}}
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}}
{\shp {\*\shpinst\shpleft4233\shptop9394\shpright7706\shpbottom9753\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,359);(3473,359);(3473,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
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}}
{\shp {\*\shpinst\shpleft4233\shptop9753\shpright4233\shpbottom9394\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft2317\shptop5296\shpright2317\shpbottom5553\shpfhdr0\shp
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sn lineWidth}{\sv 14241}}
}}
{\shp {\*\shpinst\shpleft2265\shptop5551\shpright2370\shpbottom5655\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,0);(53,104);(105,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
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}}
{\shp {\*\shpinst\shpleft4113\shptop2261\shpright4113\shpbottom2501\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft4113\shptop2980\shpright4113\shpbottom3100\shpfhdr0\shp
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sn lineWidth}{\sv 14241}}

}}
{\shp {\*\shpinst\shpleft5670\shptop3100\shpright5670\shpbottom3219\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft4113\shptop4417\shpright4113\shpbottom4537\shpfhdr0\shp
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}}
{\shp {\*\shpinst\shpleft6029\shptop8915\shpright6029\shpbottom9091\shpfhdr0\shp
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{\shp {\*\shpinst\shpleft5977\shptop9089\shpright6082\shpbottom9193\shpfhdr0\shp
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calex93 \ul0\nosupersub\cf5\f6\fs18 Otitis Media: Diagnosis and Management\tab \
up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 145\par\pard\qj \li1286
\sb0\sl-250\slmult0 \par\pard\qj\li1286\ri961\sb60\sl-250\slmult0 \up0 \expndtw10\charscalex95 ndings of an inamed tympanic membrane and middle ear eusion, in \up
0 \expndtw-10\charscalex96 a patient who has received a dose of 40 to 60 mg/kg/d
ay of amoxicillin \up0 \expndtw-10\charscalex89 for at least 72 hours\ul0\nosupe
rsub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 (p. 71). \par\pard
\ql \li2244\sb0\sl-218\slmult0 \par\pard\ql\li2244\sb0\sl-218\slmult0 \par\pard\
ql\li2244\sb121\sl-218\slmult0 \up0 \expndtw0\charscalex106 \ul0\nosupersub\cf7\
f8\fs24 D\ul0\nosupersub\cf31\f32\fs17 RUG\ul0\nosupersub\cf7\f8\fs24 T\ul0\nos
upersub\cf31\f32\fs17 REATMENT\ul0\nosupersub\cf7\f8\fs24 N\ul0\nosupersub\cf31
\f32\fs17 O\ul0\nosupersub\cf7\f8\fs24 L\ul0\nosupersub\cf31\f32\fs17 ONGER\ul0
\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UTOMATIC \par\pard\qj \l
i1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri961\sb8\sl-260\slmult0\fi478 \up0
\expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 Propelled by evidence-ba
sed medicine, the treatment paradigm \line \up0 \expndtw-9\charscalex96 for
OME is changing, and medications are no longer automatically \line \up0
\expndtw-9\charscalex96 prescribed. Now, selective rather than routine use
of antibiotics is \line \up0 \expndtw-10\charscalex95 preferred, largely bec
ause spontaneous resolution of AOM and OME is \line \up0 \expndtw-10\charscalex9
6 so common. \par\pard\ql \li1764\sb6\sl-253\slmult0 \up0 \expndtw-10\charscalex
90 The increasing resistance of S. pneumoniae, H. inuenzae, and \par\pard

\qj \li1286\ri959\sb2\sl-260\slmult0\fi0 \up0 \expndtw-7\charscalex100 M. catarr

halis to antibiotics has made treatment of OM more di\u8260?cult. \line \up0 \ex
pndtw-9\charscalex97 This factor, coupled with the growing recognition of the ro
le of viruses, \line \up0 \expndtw-9\charscalex94 has stimulated eorts to prevent
rather than to treat OME. Accordingly, a \line \up0 \expndtw-9\charscalex91 new
generation of protein conjugate S. pneumoniae bacterial vaccines that \line \up
0 \expndtw-10\charscalex91 shows promise in the prevention of OM was recently ap
proved by the \par\pard\ql \li1286\sb6\sl-253\slmult0\tx6907 \up0 \expndtw-6\cha
rscalex100 U.S. Food and Drug Administration for use in children \tab \u
p0 \expndtw-10\charscalex93 (Black, \par\pard\ql \li1286\sb7\sl-253\slmult0 \up0
\expndtw-10\charscalex92 Shineeld, & Fireman, 2000). \par\pard\qj \li1286\ri959\
sb6\sl-255\slmult0\fi478 \up0 \expndtw-10\charscalex90 Several investigators hav
e evaluated the e\u8260?cacy of shorter courses of \line \up0 \expndtw-7\charsca
lex100 antibiotic treatment in AOM. At present, the only oral drug approved \lin
e \up0 \expndtw-10\charscalex96 for use in a 5 -day regimen is azithromycin. Dou
ble-blind studies have \line \up0 \expndtw-9\charscalex96 shown that the outcome
of a 5 -day intake of azithromycin is equivalent \line \up0 \expndtw-10\charsca
lex92 to 10 days of amoxicillin-clavulanate (Pichichero & Cohen, 1997). \par\par
d\ql \li3319\sb0\sl-207\slmult0 \par\pard\ql\li3319\sb0\sl-207\slmult0 \par\pard
\ql\li3319\sb151\sl-207\slmult0 \up0 \expndtw0\charscalex103 \ul0\nosupersub\cf7
\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 URGICAL\ul0\nosupersub\cf7\f8\fs24 T\ul
0\nosupersub\cf31\f32\fs17 REATMENT \par\pard\qj \li1286\sb0\sl-260\slmult0 \par
\pard\qj\li1286\ri959\sb10\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 \u
l0\nosupersub\cf2\f3\fs22 When pharmaceutical treatment options have been
exhausted, \up0 \expndtw-9\charscalex95 surgery must be considered. In the
past decade, as an increasing \up0 \expndtw-9\charscalex93 percentage of mi
ddle ear organisms have become resistant to antibiotics, \up0 \expndtw-8\charsca
lex100 surgical treatment of OME has taken on new importance. Referral to \up0 \
expndtw-8\charscalex100 an otolaryngologist should be considered after 3 mont
hs of bilateral \up0 \expndtw-5\charscalex100 OME, particularly when there i
s no evidence of improvement \up0 \expndtw-9\charscalex93 and when hearing
loss is suspected (see Fig. 6.2) (Stool et al., 1994). \up0 \expndtw-8\chars
calex100 The many factors that favor surgical treatment of OME (Stool et al., \
up0 \expndtw-10\charscalex88 1994) are shown in Table 6.4.
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osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
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\ql\li4325\sb0\sl-207\slmult0 \par\pard\ql\li4325\sb0\sl-207\slmult0 \par\pard\q
l\li4325\sb0\sl-207\slmult0 \par\pard\ql\li4325\sb0\sl-207\slmult0 \par\pard\ql\
li4325\sb0\sl-207\slmult0 \par\pard\ql\li4325\sb0\sl-207\slmult0 \par\pard\ql\li
4325\sb0\sl-207\slmult0 \par\pard\ql\li4325\sb0\sl-207\slmult0 \par\pard\ql\li43
25\sb55\sl-207\slmult0 \up0 \expndtw-8\charscalex94 Table 6.4 \par\pard\ql \li17
27\sb73\sl-207\slmult0 \up0 \expndtw-1\charscalex100 Factors Favoring Surgical T
reatment of Chronic Otitis Media with Effusion \par\pard\ql \li1551\sb133\sl-207

\slmult0 \up0 \expndtw-8\charscalex88 Bilateral disease \par\pard\qj \li1551\ri2

041\sb3\sl-220\slmult0 \up0 \expndtw-7\charscalex95 Bilateral hearing loss (20 d
B hearing threshold level [HTL] or greater) \up0 \expndtw-8\charscalex92 Signifi
cant speech-language deficits \par\pard\ql \li1551\sb11\sl-207\slmult0 \up0 \exp
ndtw-8\charscalex93 Behavioral problems \par\pard\ql \li1551\ri2458\sb3\sl-220\s
lmult0 \up0 \expndtw-8\charscalex94 Tympanic membrane retraction \line \up0 \exp
ndtw-8\charscalex95 Ear pain or pulling \par\pard\ql \li1551\ri2905\sb0\sl-220\s
lmult0 \up0 \expndtw-6\charscalex100 Recurrent AOM \line \up0 \expndtw-8\charsca
lex100 Antibiotic allergies \par\pard\ql \li1551\ri2674\sb0\sl-220\slmult0 \up0
\expndtw-8\charscalex90 Frequent smoke exposure \line \up0 \expndtw-8\charscalex
91 Group day care \par\pard\ql \li1551\sb1\sl-195\slmult0 \up0 \expndtw-8\charsc
alex94 Persistent AOM (3 months or longer) \par\pard\qj \li1551\ri744\sb141\sl-2
00\slmult0 \up0 \expndtw-6\charscalex96 \ul0\nosupersub\cf3\f4\fs16 From Parthas
arathy, T. K., Bhat,V., & Malur, G. J. (2003). Otitis media: A primer on diagnos
is and \up0 \expndtw-6\charscalex91 management.The Hearing Journal, 56(6): 42^ 4
8. (Reprinted with permission fromThe Hearing Journal \up0 \expndtw-7\charscalex
91 and Lippincott W|lliams & W|lkins.)
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calex93 \ul0\nosupersub\cf5\f6\fs18 Otitis Media: Diagnosis and Management\tab \
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\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0\fi478 \up0 \ex
pndtw-9\charscalex100 More than 500,000 children a year in the United States und
ergo \line \up0 \expndtw-8\charscalex100 tympanostomy tube placement for chronic

OME. The AHCPR guide-\line \up0 \expndtw-10\charscalex90 lines \up0 \expndtw-8\

charscalex100 (see Fig. 6.2) recommend that a child who has persistent OME \line
\up0 \expndtw-5\charscalex100 for \up0 \expndtw-10\charscalex80 4 ^ 6 \up0 \exp
ndtw-9\charscalex100 months and who presents with a bilateral hearing lo
ss \line \up0 \expndtw-9\charscalex96 (20 dB hearing threshold level [HTL] or gr
eater) should have a bilateral \line \up0 \expndtw-7\charscalex100 myringotomy w
ith tube placement. The AHCPR did not recommend \line \up0 \expndtw-10\charscale
x95 adenoidectomy as a treatment for OME in young children between age \line \up
0 \expndtw-9\charscalex94 1 and 3 years (Stool et al., 1994). In addition, there
is little evidence that \line \up0 \expndtw-9\charscalex97 either myringotomy
alone or tonsillectomy has any signicant place \line \up0 \expndtw-9\charscal
ex100 in the management of OME. The use of steroids, antihistamines, and \line \
up0 \expndtw-10\charscalex93 decongestant medications is also not recommended in
the management \line \up0 \expndtw-10\charscalex94 of OME (Stool et al., 1994).
\par\pard\ql \li2222\sb0\sl-207\slmult0 \par\pard\ql\li2222\sb0\sl-207\slmult0
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ersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UDIOLOGIC\ul0\nosupersub\cf7\f8
\fs24 M\ul0\nosupersub\cf31\f32\fs17 ANAGEMENT\ul0\nosupersub\cf7\f8\fs24 C\ul
0\nosupersub\cf31\f32\fs17 ONSIDERATIONS \par\pard\ql \li1764\sb0\sl-253\slmult0
\par\pard\ql\li1764\sb22\sl-253\slmult0\tx5475 \up0 \expndtw-8\charscalex100 \u
l0\nosupersub\cf2\f3\fs22 The educational implications of mild, \tab \up0 \e
xpndtw-10\charscalex95 uctuating, conductive \par\pard\qj \li1286\ri959\sb5\sl-2
56\slmult0 \up0 \expndtw-9\charscalex96 hearing impairment are signicant and
must be considered in the \up0 \expndtw-10\charscalex96 management of OME.
The audiologic management considerations for \up0 \expndtw-10\charscalex96 OME s
hould include (1) information about auditory-based communica\up0 \expndtw-9\char
scalex94 tion strategies, (2) information about auditory behaviors that might si
gnal \up0 \expndtw-9\charscalex100 OM infection, and (3) information about clas
sroom accommodations, \up0 \expndtw-9\charscalex91 such as preferential seating,
peer assistance, decreasing noise oor in the \up0 \expndtw-10\charscalex91 class
room, and sound eld amplication systems. \par\pard\qj \li1286\ri961\sb1\sl-260\slm
ult0\fi478 \up0 \expndtw-10\charscalex92 Management of OME, like assessment, sho
uld be multidisciplinary. \line \up0 \expndtw-9\charscalex95 Audiologists, speec
h-language pathologists, pediatricians, otolaryngolo-\line \up0 \expndtw-9\chars
calex91 gists, teachers, and parents should be involved in the child\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s overall care. \par\pard\q
j \li1286\ri961\sb0\sl-260\slmult0\fi478 \up0 \expndtw-8\charscalex100 The Ameri
can Academy of Audiology (AAA) in 1992 issued a \up0 \expndtw-10\charscalex94
position statement recommending a three-step guideline (Table 6.5) for \up0 \ex
pndtw-10\charscalex96 children with persistent learning and communication decits
related to \up0 \expndtw-10\charscalex95 untreated or undetected OM. The AAA dev
eloped additional guidelines \up0 \expndtw-9\charscalex93 in 1997, and the A
merican Speech-Language-Hearing Association in \up0 \expndtw-10\charscalex93
1993 developed a comprehensive management program for school-age \up0 \expndtw10\charscalex94 children with undetected or untreated OM. \par\pard\qj \li1286\r
i961\sb0\sl-260\slmult0\fi478 \up0 \expndtw-9\charscalex100 A few children are a
lready at risk for learning and language pro-\line \up0 \expndtw-9\charscalex93
blems such as those from special populations with Turner\ul0\nosupersub\c
f11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s, Apert\ul0\nosupersub\cf11\f1
2\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s, \line \up0 \expndtw-8\charscalex100
or Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s syndr
ome, cleft palate/lip, any maxillofacial malformation, \line \up0 \expndtw-9\cha
rscalex93 and some groups of mentally retarded children (Roberts & Hunter, 2002)
.
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53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2903 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 148\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\li1883\sb0\sl-207\slmult0\par\pard\li1883\sb0\sl-207\slmult0\par\pard\li18
83\sb0\sl-207\slmult0\par\pard\li1883\sb0\sl-207\slmult0\par\pard\li1883\sb0\sl207\slmult0\par\pard\li1883\sb0\sl-207\slmult0\par\pard\li1883\sb0\sl-207\slmult
0\par\pard\li1883\sb0\sl-207\slmult0\par\pard\li1883\sb0\sl-207\slmult0\par\pard
\li1883\sb0\sl-207\slmult0\par\pard\li1883\sb0\sl-207\slmult0\par\pard\li1883\sb
0\sl-207\slmult0\par\pard\li1883\sb0\sl-207\slmult0\par\pard\li1883\sb33\sl-207\
slmult0\fi2437 \up0 \expndtw-1\charscalex100 Table 6.5\par\pard\li1883\sb72\sl-2
07\slmult0\fi0 \up0 \expndtw-1\charscalex100 American Academy of AudiologyAudiol
ogic Guidelines for Managing\par\pard\li1551\sb13\sl-207\slmult0\fi2062 \up0 \ex
pndtw-8\charscalex94 Otitis Media with Effusion\par\pard\li1551\sb131\sl-207\slm
ult0\fi0\tx3507\tx5714 \up0 \expndtw-8\charscalex94 Identification Process\tab \
up0 \expndtw-8\charscalex94 Assessment Process\tab \up0 \expndtw-8\charscalex94
Management Process\par\pard\sect\sectd\sbknone\cols2\colno1\colw5604\colsr110\co
lno2\colw2846\colsr160\ql \li1551\sb79\sl-207\slmult0\tx3502 \up0 \expndtw-8\cha
rscalex93 Screening for hearing,\tab \up0 \expndtw-8\charscalex96 Diagnostic aud
iologic\par\pard\ql \li1730\sb12\sl-207\slmult0\tx3681 \up0 \expndtw-8\charscale
x96 middle ear function,\tab \up0 \expndtw-8\charscalex86 assessment (pure tone,
\par\pard\ql \li1730\sb13\sl-207\slmult0\tx3681 \up0 \expndtw-8\charscalex87 and
speech and\tab \up0 \expndtw-8\charscalex90 speech audiometry,\par\pard\ql \li1
730\sb11\sl-207\slmult0\tx3681 \up0 \expndtw-8\charscalex92 language development
\tab \up0 \expndtw-8\charscalex93 acoustic, immittance,\par\pard\ql \li3686\sb12
\sl-207\slmult0 \up0 \expndtw-8\charscalex93 and formal language\par\pard\ql \li
3686\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex82 assessment)\par\pard\ql \l
i3507\sb12\sl-207\slmult0 \up0 \expndtw-8\charscalex94 Central auditory processi
ng\par\pard\ql \li3686\sb12\sl-207\slmult0 \up0 \expndtw-8\charscalex94 evaluati
on when indicated\par\pard\column \ql \li20\sb79\sl-207\slmult0 \up0 \expndtw-5\
charscalex100 Audiometric monitoring\par\pard\qj \li199\ri733\sb3\sl-219\slmult0
\up0 \expndtw-8\charscalex94 at least once during winter \up0 \expndtw-8\charsc
alex96 months\par\pard\ql \li5714\sb0\sl-219\slmult0 \par\pard\ql \li5714\sb0\sl
-219\slmult0 \par\pard\ql \li20\ri742\sb219\sl-219\slmult0\tx209\tx209\tx209 \up
0 \expndtw-8\charscalex93 Counseling to parents, \line\tab \up0 \expndtw-8\chars
calex87 caregivers, and teachers \line \tab \up0 \expndtw-8\charscalex96 on impl
ications of hearing \line \tab \up0 \expndtw-7\charscalex100 impairment on\par\p
ard\ql \li199\sb10\sl-207\slmult0 \up0 \expndtw-7\charscalex100 communication \p
ar\pard\sect\sectd\sbknone \qj \li1551\ri744\sb173\sl-200\slmult0\fi0 \up0 \expn
dtw-5\charscalex100 \ul0\nosupersub\cf3\f4\fs16 From Parthasarathy, T. K., Bhat,
V., & Malur, G. J. (2003). Otitis media: A primer on diagnosis \up0 \expndtw-6\
charscalex93 and management. The Hearing Journal, 56(6): 42^ 48. (Reprinted with
permission from The Hearing \up0 \expndtw-7\charscalex93 Journal and Lippincott
W|lliams & W|lkins.)
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41\slmult0\par\pard\li2914\sb201\sl-241\slmult0\fi0\tx7206 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Otitis Media: Diagnosis and Management\tab \
up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 149\par\pard\qj \li1286
\sb0\sl-253\slmult0 \par\pard\qj\li1286\ri961\sb55\sl-253\slmult0 \up0 \expndtw9\charscalex91 Early detection and aggressive multidisciplinary assessment and m
anage\up0 \expndtw-8\charscalex100 ment are critical to minimize the long-term a
dverse eects of hearing \up0 \expndtw-9\charscalex97 impairment on aspects of
central auditory function or processing, \up0 \expndtw-10\charscalex95 ling
uistic-cognitive function, and educational attainment. \par\pard\qj \li1286\ri95
9\sb2\sl-260\slmult0\fi478 \up0 \expndtw-9\charscalex100 Screening of children w
ith OME for academic or developmental \up0 \expndtw-9\charscalex100 decits is cri
tical. The Early Language Milestone (ELM) scale can be \up0 \expndtw-10\charsca
lex96 useful to identify decits in young children between age 1 and 3 years \up0
\expndtw-9\charscalex94 (Coplan, 1987). For identifying school-age children who
are at risk in the \up0 \expndtw-9\charscalex95 classroom, the Screening Inst
rument for Targeting Educational Risk \up0 \expndtw-10\charscalex92 (SIFTER)
(Anderson, 1989) can be very benecial. \par\pard\ql \li3744\sb0\sl-276\slmult0 \p
ar\pard\ql\li3744\sb231\sl-276\slmult0 \up0 \expndtw0\charscalex103 \ul0\nosuper
sub\cf7\f8\fs24 SUMMARY \par\pard\qj \li1286\ri960\sb258\sl-260\slmult0\fi478 \u
p0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\f3\fs22 The incidence of AOM in
children has increased during the past \line \up0 \expndtw-10\charscalex95 decad

e. The most common organisms causing AOM in children in \line \up0 \expn
dtw-9\charscalex92 the United States are S. pneumoniae, H. inuenzae, and M. c
atarrhalis. \line \up0 \expndtw-10\charscalex95 Resistance of these pathogens to
antibiotics has also increased during \line \up0 \expndtw-9\charscalex100 the p
ast decade. Because of this, the treatment paradigm for AOM is \line \up0 \expnd
tw-10\charscalex94 changing. Drug treatment is no longer automatic. Evidence-bas
ed med-\line \up0 \expndtw-7\charscalex100 icine is helping to propel this parad
igm shift in treating AOM so that \line \up0 \expndtw-10\charscalex92 selective
rather than routine use of antibiotics is preferred. \par\pard\qj \li1286\ri959\
sb5\sl-255\slmult0\fi478 \up0 \expndtw-7\charscalex100 Many factors contribute t
o an increased risk of development of \up0 \expndtw-9\charscalex100 AOM in child
ren. By clearly understanding the role these factors play \up0 \expndtw-9\charsc
alex96 and the variations in resistance patterns of bacterial pathogens in each
\up0 \expndtw-10\charscalex94 geographic community, an optimal treatment plan ca
n be developed for \up0 \expndtw-10\charscalex95 patients with AOM. \par\pard\qj
\li1286\ri959\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 Environmen
tal modications, immunizations, and pharmaceutical \line \up0 \expndtw-9\charscal
ex94 and surgical options should be considered. Pediatricians and family care \l
ine \up0 \expndtw-9\charscalex93 physicians can play an active role by educating
parents about risk factors \line \up0 \expndtw-7\charscalex100 for AOM and how
to minimize their eects. Given the potential long-\line \up0 \expndtw-10\charscal
ex95 term impact that uctuating OME-caused hearing impairment can have \line \up0
\expndtw-7\charscalex100 on central auditory function, linguistic-cognitive fun
ction, and educa-\line \up0 \expndtw-9\charscalex96 tional attainment, audiologi
sts must be vigilant and proactive to provide \line \up0 \expndtw-9\charscalex92
professional services for the early detection and nonmedical management \line \
up0 \expndtw-10\charscalex92 of OM. \par\pard\qj \li1286\ri961\sb0\sl-260\slmult
0\fi478 \up0 \expndtw-9\charscalex100 Management of OME, like assessment, s
hould be multidis-\line \up0 \expndtw-9\charscalex93 ciplinary. Audiologists
, speech-language pathologists, pediatricians,
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53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2899 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 150\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-253\slmult0 \par\pard\qj\li1551\ri696\sb82\sl-253\slmult
0 \up0 \expndtw-9\charscalex94 \ul0\nosupersub\cf2\f3\fs22 otolaryngologists, te
achers, and parents should be involved in the child\ul0\nosupersub\cf11\f12\fs22
\u8217?\ul0\nosupersub\cf2\f3\fs22 s \line \up0 \expndtw-10\charscalex97 overal
l care. Eective communication and partnership among audiolo-\line \up0 \expndtw-9
\charscalex92 gists, speech-language pathologists, day-care providers, pare
nts, and \line \up0 \expndtw-10\charscalex92 primary care providers are critica
l in the overall management of OM. \par\pard\ql \li3842\sb0\sl-276\slmult0 \par\
pard\ql\li3842\sb0\sl-276\slmult0 \par\pard\ql\li3842\sb56\sl-276\slmult0 \up0 \
expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 REFERENCES \par\pard\ql \li1
551\sb0\sl-220\slmult0 \par\pard\ql\li1551\ri728\sb71\sl-220\slmult0\fi0\tx1790\
tx1790 \up0 \expndtw-7\charscalex95 \ul0\nosupersub\cf5\f6\fs18 American Academ
y of Audiology. (1992). Position statement on guidelines for the \line\t
ab \up0 \expndtw-7\charscalex93 diagnosis and treatment of otitis media in child

ren. AudiologyToday, 4, 23 ^24. \line \up0 \expndtw-7\charscalex97 American Acad

emy of Audiology. (1997). Identication of hearing loss and middle-ear \line\tab \
up0 \expndtw-7\charscalex92 dysfunction in preschool and school-aged children. A
udiologyToday, 9, 18 ^23. \line \up0 \expndtw-8\charscalex92 American Speech-La
nguage-Hearing Association \up0 \expndtw-8\charscalex92 (ASHA). \up0 \expndtw-8
\charscalex92 (1993). Guidelines for \par\pard\ql \li1790\sb11\sl-207\slmult0
\up0 \expndtw-8\charscalex90 audiology services in the schools. ASHA Supplement,
35(3), 24 ^32. \par\pard\qj \li1551\ri728\sb3\sl-220\slmult0\tx1790 \up0 \expnd
tw-7\charscalex90 Anderson, K. L. (1989). Screening instrument for targetin
g educational risk. Danville, IL: \line\tab \up0 \expndtw-8\charscalex90 Inter
state. \par\pard\ql \li1551\ri729\sb5\sl-215\slmult0\fi0\tx1790\tx1790\tx1790 \u
p0 \expndtw-4\charscalex100 Barnett, E. D., Teele, D. W., & Klein, J. O. (1997)
. Comparison of ceftriaxone and \line\tab \up0 \expndtw-7\charscalex93 trimethop
rim-sulfamethoxazole for acute otitis media. Pediatrics, 99, 23 ^28. \line \up0
\expndtw-6\charscalex100 Black, S., Shineeld, H., & Fireman, B. (2000). E\u8260?c
acy, safety and immmunogenicity \line\tab \up0 \expndtw-7\charscalex95 of heptav
alent pneumococcal conjugate vaccine in children. The Pediatric Infectious \line
\tab \up0 \expndtw-8\charscalex78 Disease Journal, 19, 187^195. \par\pard\ql \l
i1551\ri728\sb1\sl-220\slmult0\tx1790\tx1790\tx1790 \up0 \expndtw-7\charscalex94
Block, S. L. (1997). Causative pathogens, antibiotic resistance and therapeutic
consider-\line\tab \up0 \expndtw-7\charscalex87 ations in acute otitis media.Th
e Pediatric Infectious Disease Journal, 16, 449 ^ 456. \line \up0 \expndtw-7\cha
rscalex97 Bluestone, C. D. (1994). Surgical management of otitis media: Current
indications and \line\tab \up0 \expndtw-7\charscalex91 role related to increasin
g bacterial resistance. The Pediatric Infectious Disease Journal, \line \tab \up
0 \expndtw-8\charscalex82 13,1058 ^1063. \par\pard\qj \li1551\ri729\sb0\sl-220\s
lmult0\tx1790 \up0 \expndtw-7\charscalex95 Bluestone, C. D., & Klein, J. O. (199
5). Otitis media in infants and children (pp. 34 ^57). \line\tab \up0 \expndtw-8
\charscalex91 Philadelphia: Saunders. \par\pard\qj \li1551\ri730\sb0\sl-220\slmu
lt0\tx1790 \up0 \expndtw-6\charscalex100 Bluestone, C. D., Stephenson, J. S., &
Martin, L. M. (1992). Ten year review of otitis \line\tab \up0 \expndtw-8\charsc
alex84 media pathogens.The Pediatric Infectious Disease Journal, 11, 7^11. \par\
pard\ql \li1551\ri729\sb0\sl-220\slmult0\tx1790\tx1790 \up0 \expndtw-7\charscale
x98 Casselbrant, M. L., Mandel, E. M., & Fall, P. A. (1999). The heritability of
otitis media: \line\tab \up0 \expndtw-7\charscalex93 A twin and triplet study.
JAMA: The Journal of the American Medical Association, 282, \line \tab \up0 \exp
ndtw-8\charscalex83 2125 ^2130. \par\pard\ql \li1551\sb11\sl-207\slmult0 \up0 \e
xpndtw-7\charscalex93 Coplan, J. (1987).The Early Language Milestone Scale (ELM)
. Austin,TX: PRO-ED. \par\pard\qj \li1551\ri727\sb3\sl-220\slmult0\tx1790 \up0 \
expndtw-6\charscalex100 Daly, K. A., Hunter, L. L., & Giebink, G. S. (1999). Chr
onic otitis media. Pediatrics in \line\tab \up0 \expndtw-8\charscalex84 Review,
20, 85 ^93. \par\pard\ql \li1551\ri727\sb0\sl-220\slmult0\tx1790\tx1790\tx1790\t
x1790 \up0 \expndtw-7\charscalex100 Doern, G. V., Brueggemann, A. B., & Pierce,
G. (1997). Antibiotic resistance among \line\tab \up0 \expndtw-7\charscalex93 c
linical isolates of Haemophilus inuenzae in the United States in 1994 and 1995 an
d \line \tab \up0 \expndtw-7\charscalex95 detection of\ul0\nosupersub\cf35\f36\f
s18 b\ul0\nosupersub\cf5\f6\fs18 -lactamase positive strains resistant to amoxi
cillin-clavulanate: Results \line \tab \up0 \expndtw-7\charscalex94 of a nationa
l multicenter surveillance study. Antimicrobial Agents and Chemotherapy, \line \
tab \up0 \expndtw-8\charscalex94 41,292^297.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
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41\slmult0\par\pard\li2914\sb201\sl-241\slmult0\fi0\tx7215 \up0 \expndtw-8\chars
calex93 \ul0\nosupersub\cf5\f6\fs18 Otitis Media: Diagnosis and Management\tab \
up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 151\par\pard\qj \li1286
\sb0\sl-220\slmult0 \par\pard\qj\li1286\ri995\sb75\sl-220\slmult0\tx1525 \up0 \e
xpndtw-4\charscalex100 \ul0\nosupersub\cf5\f6\fs18 Gravel, J. S., & Ellis, M. A.
(1995). Examining the auditory consequences of otitis \line\tab \up0 \expndtw8\charscalex89 media: The audiogram beyond. Seminars in Hearing, 16, 44 ^59. \pa
r\pard\ql \li1286\ri994\sb0\sl-220\slmult0\tx1525\tx1525 \up0 \expndtw-7\charsca
lex94 Gravel, J. S., & Wallace, I. F. (1992). Listening and language at 4 years
of age: Eects of \line\tab \up0 \expndtw-7\charscalex85 early otitis media. Journ
al of Speech and Hearing Research, 35, 588 ^595. \line \up0 \expndtw-7\charscale
x93 Gravel, J. S., & Wallace, I. F. (1995). Early otitis media, auditory abiliti
es, and educational \line\tab \up0 \expndtw-8\charscalex82 risk. American Journa
l of Speech-Language Pathology, 4, 89 ^94. \par\pard\ql \li1286\ri992\sb0\sl-220
\slmult0\fi0\tx1525\tx1525 \up0 \expndtw-5\charscalex100 Gravel, J. S., & Wallac
e, I. F. (2000). Eects of otitis media with eusion on hearing \line\tab \up0 \expn
dtw-7\charscalex87 in the rst 3 years of life. Journal of Speech and Hearing Rese
arch, 43, 631^ 644. \line \up0 \expndtw-7\charscalex95 Hoberman, A., Paradise,
J. L., & Wald, E. R. (1997). Tympanocentesis technique \line\tab \up0 \
expndtw-7\charscalex86 revisited.The Pediatric Infectious Disease Journal, 16(Su
ppl. 2), 25 ^26. \par\pard\ql \li1286\ri993\sb0\sl-220\slmult0\tx1525\tx1525 \up
0 \expndtw-4\charscalex100 Hunter, L. L., Margolis, R. H., Ryyken, J. R., Le, C.
T., Dayly, A., & Giebink, G. S. \line\tab \up0 \expndtw-7\charscalex93 (1996).
High frequency hearing loss associated with otitis media. Ear and Hearing, 17, \
line \tab \up0 \expndtw-8\charscalex87 1^11. \par\pard\qj \li1286\ri994\sb0\sl-2
20\slmult0\tx1525 \up0 \expndtw-7\charscalex97 Linsk, R., Gilsdorf, J., & Lesper
ance, M. (1999). When amoxicillin fails. Contemporary \line\tab \up0 \expndtw-8\
charscalex79 Pediatrics, 16, 67^ 88. \par\pard\qj \li1286\ri994\sb0\sl-220\slmul
t0\tx1525 \up0 \expndtw-7\charscalex92 McCraken, G. H. (1995). Emergence of resi
stant Streptococcus pneumoniae: A problem in \line\tab \up0 \expndtw-8\charscale
x83 pediatrics.The Pediatric Infectious Disease Journal, 14, 424 ^ 428. \par\par
d\qj \li1286\ri994\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-7\charscalex100 Papar
ella, M. M., Bluestone, C. D., & Arnold, W. (1985). Denition and classication. \li
ne\tab \up0 \expndtw-8\charscalex85 Annals of Otology, Rhinology, and Laryngolol
ogy, 94, 8 ^9. \par\pard\ql \li1286\ri993\sb0\sl-220\slmult0\tx1525\tx1525 \up0
\expndtw-7\charscalex96 Pichichero, M. E., & Cohen, R. (1997). Shortened course
of antibiotic therapy for acute \line\tab \up0 \expndtw-7\charscalex90 otitis me
dia, sinusitis and tonsillopharyngitis.The Pediatric Infectious DiseaseJournal,
16, \line \tab \up0 \expndtw-8\charscalex82 680 ^ 695. \par\pard\qj \li1286\ri99
4\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-6\charscalex100 Roberts, J., & Hunter,
L. (2002). Otitis media and children\ul0\nosupersub\cf10\f11\fs18 \u8217?\ul0\
nosupersub\cf5\f6\fs18 s language and learning. \line\tab \up0 \expndtw-8\charsc
alex85 ASHA Leader, 7, 18 ^19. \par\pard\li1286\sb1\sl-196\slmult0\fi0 \up0 \exp
ndtw-7\charscalex97 Roseneld, R. M., Vertrees, J. E., Carr, J., Cippole, R. J., U
den, D. L., Giebink, G. S.,\par\pard\li1286\sb14\sl-207\slmult0\fi239\tx2048 \up
0 \expndtw-8\charscalex96 et al.\tab \up0 \expndtw-7\charscalex97 (1994). Clin
ical e\u8260?cacy of antimicrobial drugs for acute otitis media:\par\par
d\li1286\sb13\sl-207\slmult0\fi239\tx2808\tx3265 \up0 \expndtw-8\charscalex95 Me
taanalysis of\tab \up0 \expndtw-8\charscalex90 5400\tab \up0 \expndtw-8\charsca
lex96 children from thirty-three randomized trials. Journal of\par\pard\li
1286\sb12\sl-207\slmult0\fi239 \up0 \expndtw-8\charscalex96 Pediatrics, 124, 355
^367.\par\pard\qj \li1286\ri993\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-7\chars
calex97 Schappert, S. M. (1992). O\u8260?ce visits for otitis media: United Stat
es, 1975 ^90. National \line\tab \up0 \expndtw-8\charscalex83 Center for Health
Statistics, 214, 1^18. \par\pard\ql \li1286\ri993\sb0\sl-220\slmult0\tx1525\tx15
25\tx1525 \up0 \expndtw-7\charscalex97 Stool, S. E., Berg, A. O. & Berman, S. (1
994, July). Otitis media with eusion in young \line\tab \up0 \expndtw-6\charscale

x100 children. Clinical Practice Guideline No. 12 (AHCPR Publication No. 94 0622). \line \tab \up0 \expndtw-7\charscalex100 Rockville, MD: U.S. Department o
f Health and Human Services. \line \up0 \expndtw-7\charscalex98 Stool, S. E., &
Field, M. J. (1989) The impact of otitis media. The Pediatric Infectious \line
\tab \up0 \expndtw-8\charscalex79 Disease Journal, 8, 11^14. \par\pard\ql \li128
6\ri994\sb0\sl-220\slmult0\tx1525\tx1525 \up0 \expndtw-7\charscalex96 Teele, D.W
., Klein, J. O., Rosner, B. A. (1989). Epidemiology of otitis media during the \
line\tab \up0 \expndtw-6\charscalex100 rst seven years of life in children in gre
ater Boston: a prospective, cohort study. \line \tab \up0 \expndtw-8\charscalex8
1 Journal of Infectious Disease, 160, 83 ^94. \par\pard\ql \li1286\ri992\sb0\sl220\slmult0\tx1525\tx1525 \up0 \expndtw-7\charscalex100 Wright, P. F., McConnel,
K. B., & Thompson, J. M. (1985). A longitudinal study of the \line\tab \up0 \ex
pndtw-7\charscalex95 detection of otitis media in the rst two years of life. Inte
rnational Journal of Pediatric \line \tab \up0 \expndtw-8\charscalex83 Otolaryng
ology, 10, 245 ^252.
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b0\sl-240{\bkmkstart Pg173}{\bkmkend Pg173}\par\pard\ql \li3339\sb0\sl-368\slmul
t0 \par\pard\ql\li3339\sb0\sl-368\slmult0 \par\pard\ql\li3339\sb0\sl-368\slmult0
\par\pard\ql\li3339\sb212\sl-368\slmult0 \up0 \expndtw0\charscalex114 \ul0\nosu
persub\cf28\f29\fs32 CHAPTER 7 \par\pard\ql \li2945\sb0\sl-368\slmult0 \par\pard
\ql\li2945\sb344\sl-368\slmult0 \up0 \expndtw0\charscalex86 \ul0\nosupersub\cf29
\f30\fs32 Cerumen Management \par\pard\ql \li2050\sb0\sl-253\slmult0 \par\pard\q
l\li2050\sb74\sl-253\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf2\f3
\fs22 John M.A. Oyiborhoro, Ed.D., F.A.A.A., CCC-A \par\pard\ql \li3471\ri3176\s
b18\sl-240\slmult0\tx3804 \up0 \expndtw-4\charscalex100 \ul0\nosupersub\cf6\f7\f
s20 Boro Audiology Clinic \line\tab \up0 \expndtw-4\charscalex100 Brooklyn, NY \
par\pard\ql \li4250\sb9\sl-230\slmult0 \up0 \expndtw-9\charscalex92 and \par\par
d\ql \li2581\sb10\sl-230\slmult0 \up0 \expndtw-8\charscalex100 National Institut
e for People with Disabilities \par\pard\ql \li3780\sb10\sl-230\slmult0 \up0 \ex
pndtw-4\charscalex100 New York, NY \par\pard\ql \li2840\sb0\sl-230\slmult0 \par\
pard\ql\li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb0\sl-230\slmult0 \par\pa
rd\ql\li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb90\sl-230\slmult0 \up0 \ex
pndtw-5\charscalex100 What Is Cerumen? \par\pard\ql \li2840\sb10\sl-230\slmult0
\up0 \expndtw-4\charscalex100 Impact of Excessive Cerumen \par\pard\ql \li2840\r
i2595\sb22\sl-240\slmult0\tx3319 \up0 \expndtw-4\charscalex100 Cerumen Managemen
t Procedures \line\tab \up0 \expndtw-9\charscalex94 Cerumen Removal Hazards \par
\pard\qj \li3319\ri2746\sb4\sl-260\slmult0 \up0 \expndtw-8\charscalex100 Contrai
ndications to Irrigation \line \up0 \expndtw-9\charscalex96 Softening of the Cer
umen \par\pard\qj \li2840\ri2358\sb0\sl-260\slmult0\fi478 \up0 \expndtw-9\charsc
alex96 Irrigation of the External Ear Canal \up0 \expndtw-9\charscalex97 Referen
ces \par\pard\ql \li2840\sb5\sl-230\slmult0 \up0 \expndtw-7\charscalex100 Select
ed Readings \par\pard\qj \li1286\sb0\sl-264\slmult0 \par\pard\qj\li1286\sb0\sl-2
64\slmult0 \par\pard\qj\li1286\ri959\sb74\sl-264\slmult0\fi478 \up0 \expndtw-10\
charscalex95 \ul0\nosupersub\cf2\f3\fs22 It is well documented that impacted cer
umen is a common occur-\line \up0 \expndtw-9\charscalex92 rence among consumer
s, especially those who are mentally retarded \line \up0 \expndtw-8\charsc
alex100 (Brister, Fullwood, Ripp, & Blodgett, 1986; Crandell & Roeser, 1993; \li
ne \up0 \expndtw-7\charscalex100 Fulton & Gri\u8260?n, 1967). In addition

to the deleterious eects that \line \up0 \expndtw-9\charscalex94 impacted cer

umen has on the consumer, the clinician has other practical \line \up0 \expndtw10\charscalex97 concerns. A clear ear canal is important to perform several audi
ologic \line \up0 \expndtw-10\charscalex97 procedures. For instance, procedures
such as the use of probe tips in \line \up0 \expndtw-9\charscalex93 immittance m
easures, use of insert earphones, taking of ear impressions \line \up0 \expndtw9\charscalex95 for custom hearing aids or earmolds, obtaining of otoacoustic emi
ssions \line \up0 \expndtw-10\charscalex95 (OAEs) and real ear measurements,
and electronystagmography all \par\pard\ql \li4278\sb0\sl-207\slmult0 \par\p
ard\ql\li4278\sb57\sl-207\slmult0 \up0 \expndtw-8\charscalex81 \ul0\nosupersub\c
f5\f6\fs18 153 \par\pard\qj \li3067\ri2882\sb0\sl-160\slmult0\fi65 \up0 \expndtw
0\charscalex100 \ul0\nosupersub\cf30\f31\fs12 Aural Rehabilitation for People wi
th Disabilities \line \up0 \expndtw0\charscalex100 Copyright \up0 \expndtw-2\cha
rscalex100 2005, Elsevier Inc. All rights reserved.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
174}{\bkmkend Pg174}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2899 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 154\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-253\slmult0 \par\pard\qj\li1551\ri697\sb82\sl-253\slmult
0 \up0 \expndtw-9\charscalex92 \ul0\nosupersub\cf2\f3\fs22 require clear ear
canals to be successfully and eectively completed. \up0 \expndtw-10\charscal
ex95 Excessive cerumen accumulation in the ear canal can be considered a \up0 \e
xpndtw-9\charscalex97 fairly serious health issue among people with disabilities
that needs to \up0 \expndtw-10\charscalex94 be attended to in rehabilitation. \
par\pard\qj \li1551\ri696\sb2\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93
Except for elderly persons, the incidence of impacted cerumen \up0 \expn
dtw-10\charscalex97 among consumers is much higher than that in the general popu
lation; \up0 \expndtw-10\charscalex95 it ranges between 22 and 36% (Brister et a
l., 1986; Crandell & Roeser, \up0 \expndtw-10\charscalex93 1993; Fulton & Gri\u8
260?n, 1967; Nudo, 1965; Oyiborhoro, 1993). \par\pard\ql \li3423\sb0\sl-276\slmu
lt0 \par\pard\ql\li3423\sb231\sl-276\slmult0 \up0 \expndtw0\charscalex100 \ul0\n
osupersub\cf7\f8\fs24 WHAT IS CERUMEN? \par\pard\qj \li1551\ri695\sb258\sl-260\s
lmult0\fi478 \up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 Cerumen
(earwax) is a viscous, sticky, and oily substance that \up0 \expndtw-8\ch
arscalex100 covers the surface linings of the external auditory canal. Cerumen i
s \up0 \expndtw-9\charscalex94 produced from secretions of the sebaceous a

nd ceruminous glands \up0 \expndtw-9\charscalex95 located in the cartilaginous

portion of the external auditory canal. These \up0 \expndtw-9\charscalex92 secr
etions are mixed with dead epithelial cells and foreign bodies, such as \up0 \ex
pndtw-10\charscalex93 dust, and form cerumen. Cerumen serves several useful prot
ective func\up0 \expndtw-9\charscalex95 tions: (1) It helps repel water and clea
ns and lubricates the external ear \up0 \expndtw-9\charscalex97 canal; (2) it he
lps to trap foreign bodies such as dust, dirt, and insects; \up0 \expndtw-9\char
scalex94 and (3) it helps to protect the ear against possible bacterial invasion
and \up0 \expndtw-10\charscalex94 fungal growth (Stone & Fulghum, 1984). \par\p
ard\qj \li1551\ri694\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex93 Howe
ver, despite its protective functions, cerumen becomes a \line \up0 \expn
dtw-9\charscalex93 health issue among people with disabilities, particularly men
tally retarded \line \up0 \expndtw-10\charscalex94 consumers, when its accumulat
ion in the ear canal becomes excessive. \line \up0 \expndtw-10\charscalex96 Ceru
men may become hard and dry due to atrophy of the ceruminous \line \up0 \expndtw
-10\charscalex97 glands (Kirkwood, 1993). Cerumen impaction results when its na
tural \line \up0 \expndtw-9\charscalex94 state is altered and the material becom
es hard, thereby slowing down or \line \up0 \expndtw-10\charscalex97 rendering i
ts natural self-removal and cleaning mechanism during jaw \line \up0 \expndtw-7\
charscalex100 movements chewing, talking, or laughing ineective. Failure to e
\u8260?-\line \up0 \expndtw-9\charscalex100 ciently remove excessive cerumen fro
m the ear canal adds to further \line \up0 \expndtw-10\charscalex95 accumulation
and build-up of the substance. Increased sebaceous and \line \up0 \expndtw-9\ch
arscalex98 ceruminous glandular activities result in increased production of cer
u-\line \up0 \expndtw-9\charscalex91 men. Also, external ear canal abnormalities
, such as those seen in Down\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub
\cf2\f3\fs22 s \line \up0 \expndtw-10\charscalex91 syndrome with its high in
cidence of stenotic \up0 \expndtw-10\charscalex91 (narrow) ear canals \par\p
ard\qj \li1551\ri696\sb1\sl-260\slmult0 \up0 \expndtw-9\charscalex100 (Northern
& Downs, 1984) or collapsible ear canals interfere with the \up0 \expndtw-9\char
scalex91 normal self-cleansing of the external auditory canal. This causes exces
sive \up0 \expndtw-10\charscalex91 cerumen build-up and impaction in the ear can
al.
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175}{\bkmkend Pg175}\par\pard\li3569\sb0\sl-241\slmult0\par\pard\li3569\sb0\sl-2
41\slmult0\par\pard\li3569\sb201\sl-241\slmult0\fi0\tx7210 \up0 \expndtw-8\chars
calex92 \ul0\nosupersub\cf5\f6\fs18 Cerumen Management\tab \up0 \expndtw-10\char
scalex92 \ul0\nosupersub\cf2\f3\fs22 155\par\pard\ql \li2354\sb0\sl-276\slmult0
\par\pard\ql\li2354\sb13\sl-276\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosup
ersub\cf7\f8\fs24 IMPACT OF EXCESSIVE CERUMEN \par\pard\qj \li1286\ri960\sb238\s
l-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 On
e major consequence of excessive or impacted cerumen in the \line \up0 \expndtw9\charscalex94 ear canal is that it is a common cause of conductive hearing impa
irment, \line \up0 \expndtw-10\charscalex94 especially among consumers with
mental retardation \up0 \expndtw-10\charscalex94 (Bricco, \up0 \expndtw-10\char
scalex78 1985; \par\pard\qj \li1286\ri960\sb0\sl-260\slmult0 \up0 \expndtw-9\cha
rscalex91 Crandell & Roeser, 1993; Ruby, 1986). Excessive cerumen blocks
or \line \up0 \expndtw-9\charscalex94 reduces the amount of sound that is tran
smitted to the inner ear through \line \up0 \expndtw-9\charscalex91 the external

ear canal. The degree of the resulting conductive hearing loss \line \up0 \expn
dtw-10\charscalex92 depends on the amount of accumulated cerumen and blockage. C
randell \line \up0 \expndtw-10\charscalex91 and Roeser (1993) reported that 80%
of ear canal occlusion may cause a \line \up0 \expndtw-10\charscalex94 mild degr
ee of conductive hearing loss, whereas a completely occluded \line \up0 \expndtw
-10\charscalex91 ear canal can cause a \up0 \expndtw-10\charscalex81 40 ^ 45
\up0 \expndtw-10\charscalex95 dB conductive hearing impairment. \par\pard\qj
\li1286\ri962\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex95 Symptoms and oth
er problems that are associated with impacted ceru\up0 \expndtw-9\charscalex97 m
en include, but are not limited to, tinnitus, dizziness, or vertigo; pain; \up0
\expndtw-9\charscalex97 itching; and otitis externa (inammation of the external a
uditory canal) \up0 \expndtw-10\charscalex89 (Adams, Boies, & Papparella, 1978;
Kirkwood, 1993). \par\pard\qj \li1286\ri961\sb0\sl-260\slmult0\fi478 \up0 \expnd
tw-10\charscalex96 As indicated earlier, the occurrence of impacted cerumen amon
g \line \up0 \expndtw-9\charscalex95 consumers with mental retardation is c
onsiderably higher than that \line \up0 \expndtw-10\charscalex95 in the non
^mentally retarded population \up0 \expndtw-10\charscalex91 (Crandell & Roes
er, 1993; \par\pard\qj \li1286\ri959\sb2\sl-258\slmult0 \up0 \expndtw-9\charsca
lex91 Nudo, 1965). For instance, Crandell and Roeser (1993) found an incidence \
line \up0 \expndtw-9\charscalex100 of excessive and impacted cerumen of 28% in
the mentally retarded \line \up0 \expndtw-9\charscalex100 population compared wi
th an incidence of 2^ 6% in subjects from the \line \up0 \expndtw-8\charscalex10
0 general adult population. They concluded that the ears of individuals \line \u
p0 \expndtw-9\charscalex93 with mental retardation have more propensity to devel
op excessive ceru-\line \up0 \expndtw-9\charscalex93 men and, thus, exhibit the
attendant consequences of varying degrees of \line \up0 \expndtw-8\charscalex100
conductive hearing loss, including its impact on cognitive, social, and \line \
up0 \expndtw-9\charscalex95 linguistic development. It is quite possible that gr
eater amounts of ceru-\line \up0 \expndtw-9\charscalex94 men are produced in men
tally retarded consumers with other disabilities \line \up0 \expndtw-10\charscal
ex95 such as cerebral palsy than in non^mentally retarded consumers, but a \line
\up0 \expndtw-9\charscalex97 lack of periodic audiologic services, which oe
r an opportunity for \line \up0 \expndtw-10\charscalex97 early identication of
excessive wax build-up and necessary follow-up \line \up0 \expndtw-9\charscalex
92 for cerumen management, to these consumers can also be a factor \li
ne \up0 \expndtw-9\charscalex97 (Oyiborhoro, 1993). It is di\u8260?cult for cons
umers with signicant cognitive \line \up0 \expndtw-9\charscalex100 decits or sever
e physical disabilities to maintain good aural hygiene \line \up0 \expndtw-9\cha
rscalex93 without assistance. Because of the high incidence of excessive
and \line \up0 \expndtw-10\charscalex91 impacted cerumen among consumers a
nd the consequent audiologic \line \up0 \expndtw-10\charscalex94 and otologic
sequelae, cerumen management should be considered an \line \up0 \expndtw-10\cha
rscalex91 important health service issue.
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scalex96 \ul0\nosupersub\cf2\f3\fs22 156\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri695\sb70\sl-260\slmult

0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 In addition

to causing conductive hearing loss and having an \up0 \expndtw-8\charscal
ex100 indirect impact on the cognitive, social, and linguistic development of \u
p0 \expndtw-10\charscalex95 consumers, excessive cerumen accumulation in the ear
canal can also \up0 \expndtw-9\charscalex92 cause consumers to experience t
innitus, dizziness, itching, pain, and \up0 \expndtw-9\charscalex93 discomfo
rt. Otitis externa can result from the presence of excessive \up0 \expn
dtw-10\charscalex93 cerumen in the ear canal. \par\pard\qj \li1551\ri694\sb0\sl263\slmult0\fi478 \up0 \expndtw-10\charscalex93 Earlier studies in which hig
h incidences of excessive cerumen \line \up0 \expndtw-10\charscalex92 among
mentally retarded consumers were investigated involved subjects \line \up0 \expn
dtw-8\charscalex100 who were selected from institutionalized populations (Fulton
& Gri\u8260?n, \line \up0 \expndtw-10\charscalex96 1967; Nudo, 1965) at a time
when audiologic services were not readily \line \up0 \expndtw-9\charscalex98 ava
ilable or mandatory as a health service for people with disabilities. \line \up0
\expndtw-9\charscalex100 However, as more recent studies show, in individuals w
ith disabilities \line \up0 \expndtw-8\charscalex100 from facilities in which au
diologic services are available regularly, the \line \up0 \expndtw-7\charscalex1
00 incidence of impacted cerumen is no higher than that of the general \line \up
0 \expndtw-10\charscalex96 population \up0 \expndtw-10\charscalex95 (Oyiborhoro,
1993). This is because follow-up cerumen \line \up0 \expndtw-10\charscale
x96 management is instituted when the problem is observed, and the con-\line \up
0 \expndtw-9\charscalex92 sumer is monitored to ensure that the problem does not
become a serious \line \up0 \expndtw-10\charscalex89 health issue. Personal and
ear hygiene may be an issue among consumers \line \up0 \expndtw-9\charscalex95
with signicant cognitive decits and physical handicaps, but audiologic \line \up0
\expndtw-10\charscalex91 services including cerumen management should not be an
issue. \par\pard\ql \li2168\sb0\sl-276\slmult0 \par\pard\ql\li2168\sb0\sl-276\sl
mult0 \par\pard\ql\li2168\sb113\sl-276\slmult0 \up0 \expndtw0\charscalex102 \ul0
\nosupersub\cf7\f8\fs24 CERUMEN MANAGEMENT PROCEDURES \par\pard\qj \li1551\ri694
\sb235\sl-263\slmult0\fi478 \up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3
\fs22 Cerumen management in many consumers is denitely more chal-\line \up0 \expn
dtw-8\charscalex100 lenging than that in the general population. The choice of p
rocedure \line \up0 \expndtw-8\charscalex100 must be appropriate for the disabil
ity that the consumer presents. At \line \up0 \expndtw-9\charscalex93 one extrem
e are consumers who are so spastic that their heads are tilted \line \up0 \expnd
tw-4\charscalex100 to the right or left, permanently close to the shoulder. At t
he other \line \up0 \expndtw-10\charscalex97 extreme are consumers who are so hy
potonic that it is di\u8260?cult for them \line \up0 \expndtw-6\charscalex100 to
keep and maintain their heads in a suitable position for cerumen \line \up0 \ex
pndtw-10\charscalex94 removal. In between the two extremes are consumers who oft
en experi-\line \up0 \expndtw-10\charscalex95 ence sudden jerky and strong
involuntary upper body movements \line \up0 \expndtw-9\charscalex91 (such as
those with athetosis) that may make cerumen management \line \up0 \expn
dtw-9\charscalex93 rather hazardous if extreme caution is not taken. As previous
ly indicated, \line \up0 \expndtw-9\charscalex100 the disability presented by a
consumer should dictate the appropriate \line \up0 \expndtw-10\charscalex90 ceru
men management technique(s) used.
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41\slmult0\par\pard\li3569\sb201\sl-241\slmult0\fi0\tx7215 \up0 \expndtw-8\chars
calex92 \ul0\nosupersub\cf5\f6\fs18 Cerumen Management\tab \up0 \expndtw-10\char
scalex92 \ul0\nosupersub\cf2\f3\fs22 157\par\pard\ql \li2908\sb0\sl-207\slmult0
\par\pard\ql\li2908\sb139\sl-207\slmult0 \up0 \expndtw0\charscalex105 \ul0\nosup
ersub\cf7\f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 ERUMEN\ul0\nosupersub\cf7\f8\fs
24 R\ul0\nosupersub\cf31\f32\fs17 EMOVAL\ul0\nosupersub\cf7\f8\fs24 H\ul0\nosu
persub\cf31\f32\fs17 AZARDS \par\pard\qj \li1286\ri959\sb250\sl-260\slmult0\fi47
8 \up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 Because of the healt
h issues with consumers, it is important to note \line \up0 \expndtw-9\charscale
x95 potential hazards that the clinician is likely to encounter during cerumen \
line \up0 \expndtw-10\charscalex94 removal. This allows more time to prepare so
that complications can be \line \up0 \expndtw-10\charscalex91 better addressed i
f they arise in the process of cerumen removal. \par\pard\qj \li1286\ri959\sb0\s
l-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 If cerumen removal instrume
nts are not handled properly, the \line \up0 \expndtw-10\charscalex93 sudde
n, involuntary movements often experienced by patients with athe-\line \up0 \exp
ndtw-7\charscalex100 tosis can cause scratching of the thin and delicate epithel
ial lining of \line \up0 \expndtw-9\charscalex91 the external ear canal, which m
ay cause bleeding. There is also a potential \line \up0 \expndtw-9\charscalex95
that the tympanic membrane could be perforated. If the irrigating nozzle \line \
up0 \expndtw-9\charscalex97 is not well directed, the water pressure from the ir
rigation instrument is \line \up0 \expndtw-7\charscalex100 too high, and if a no
nexible curette is used, serious injury could be \line \up0 \expndtw-10\charscale
x94 inicted. Thus disposable and more \up0 \expndtw-10\charscalex91 exible pla
stic curettes that are \par\pard\qj \li1286\ri959\sb0\sl-260\slmult0 \up0 \ex
pndtw-6\charscalex100 likely to cause less trauma in the event of involuntary mo
vement of \up0 \expndtw-9\charscalex100 body parts often encountered with patien
ts with spastic athetosis are \up0 \expndtw-10\charscalex96 commonly used. Exa
mples of plastic and disposable curettes are \up0 \expndtw-10\charscalex89
displayed in Fig. 7.1. \par\pard\qj \li1286\ri961\sb4\sl-256\slmult0\fi478 \up0
\expndtw-10\charscalex93 Caution should be exercised when removing cerumen that
is rmly \up0 \expndtw-9\charscalex97 attached to or embedded in the wall of the
ear canal. If this cerumen is \up0 \expndtw-9\charscalex98 forcefully removed, t
he upper lining of the canal wall will peel, thereby \up0 \expndtw-9\charscalex9
3 causing damage to the underlying tissues and bleeding (Serra, 1982). \up0
\expndtw-9\charscalex98 This trauma of cerumen extraction on the auditory
canal walls can \up0 \expndtw-10\charscalex93 provoke otitis externa (Ford & Co
urteney-Harris, 1990). \par\pard\qj \li1286\ri959\sb1\sl-260\slmult0\fi478 \up0
\expndtw-10\charscalex100 The use of irrigating uid at a temperature of 37 C is s
uggested, \line \up0 \expndtw-9\charscalex93 because uctuations in irrigating wat
er temperature in the ear canals can \line \up0 \expndtw-10\charscalex96 cause v
ertigo, nausea, and vomiting (Zivic & King, 1993). The external \line \up0 \expn
dtw-9\charscalex94 auditory canal is innervated with major cranial nerves. These
include the \line \up0 \expndtw-9\charscalex97 auricular branch of the vagus ne
rve (cranial nerve X), the auriculotem-\line \up0 \expndtw-9\charscalex96 poral
branch of the trigeminal nerve (cranial nerve V), and the posterior \line \up0 \
expndtw-9\charscalex95 auricular branch of the facial nerve (cranial nerve VII).
As a result of this \line \up0 \expndtw-7\charscalex100 network of major crania
l nerves, the external auditory canal is quite \line \up0 \expndtw-8\charscalex
100 sensitive, and when it is ordinarily stimulated, it may cause sneezing, \lin
e \up0 \expndtw-9\charscalex95 coughing, fainting, dizziness, and vomiting.
These reactions can be \line \up0 \expndtw-9\charscalex100 magnied in people w
ith disabilities who present more serious health \line \up0 \expndtw-10\charscal
ex77 issues. \par\pard\qj \li1286\ri959\sb0\sl-260\slmult0\fi478 \up0 \expndtw-7
\charscalex100 Beyond noting of the potential complications, other initial steps
\line \up0 \expndtw-9\charscalex97 include otoscopic examination and obtain
ing of a medical history.
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500145145001451450014514500145145007ffd9}}}}}\pard\sb0\sl-240{\bkmkstart Pg179}{
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mult0\par\pard\li1286\sb201\sl-241\slmult0\fi2283\tx7210 \up0 \expndtw-8\charsca
lex95 \ul0\nosupersub\cf5\f6\fs18 Cerumen Management\tab \up0 \expndtw-10\charsc
alex95 \ul0\nosupersub\cf2\f3\fs22 159\par\pard\li1286\sb0\sl-207\slmult0\par\pa
rd\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\
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rd\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb43\sl-207\slmult0\fi0\tx2210 \up0
\expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 Figure 7.1\tab \up0 \expndt
w-8\charscalex95 Continued\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\
sb0\sl-240{\bkmkstart Pg180}{\bkmkend Pg180}\par\pard\li1551\sb0\sl-253\slmult0\
par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx29
03 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 160\tab \up0 \expnd
tw-8\charscalex96 \ul0\nosupersub\cf5\f6\fs18 Audiologic Rehabilitation for Peop
le with Disabilities\par\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\
ri698\sb70\sl-260\slmult0 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\f

s22 Information from these procedures will determine whether cerumen \up0 \
expndtw-10\charscalex89 management is necessary for a consumer. \par\pard\ql \li
3405\sb0\sl-253\slmult0 \par\pard\ql\li3405\sb113\sl-253\slmult0 \up0 \expndtw-4
\charscalex100 Otoscopy/V|deo-Otoscopy \par\pard\qj \li1551\ri695\sb142\sl-260\s
lmult0\fi478 \up0 \expndtw-10\charscalex91 The purpose of otoscopic examination
of the ear canal is to evaluate \line \up0 \expndtw-8\charscalex100 the extent o
f impaction whether it is partial or complete and whether \line \up0 \expndtw6\charscalex100 the occluding object is indeed cerumen or some other foreign bod
y \line \up0 \expndtw-9\charscalex97 (such as an insect, a broken head of a Q-ti
p, or a stone). Another goal \line \up0 \expndtw-10\charscalex96 of otoscopic ex
amination is to determine whether the external auditory \line \up0 \expndtw-9\ch
arscalex95 canal is inamed or whether it is infected, which will necessitate a re
fer-\line \up0 \expndtw-9\charscalex98 ral for medical treatment. During otoscop
ic examination, in addition to \line \up0 \expndtw-10\charscalex96 gathering evi
dence for possible contraindications to cerumen removal, \line \up0 \expndtw-9\c
harscalex96 the clinician is also able to select cerumen removal techniques that
are \line \up0 \expndtw-10\charscalex95 most appropriate for the consumer and d
etermine whether softening of \line \up0 \expndtw-10\charscalex90 the cerumen fo
r a few days is necessary before removal. \par\pard\qj \li1551\ri696\sb0\sl-260\
slmult0\fi478 \up0 \expndtw-9\charscalex93 If a video-otoscope is used, a third
party is also able to view the ear \up0 \expndtw-8\charscalex100 canal when the
clinician explains the extent of the problem (Fig. 7.2). \up0 \expndtw-9\charsca
lex94 Usually the consumer is excited about being a part of this proces
s. \up0 \expndtw-9\charscalex100 In most cases the tympanic membrane cannot be v
isualized when an \up0 \expndtw-10\charscalex90 excessive amount of cerumen is p
resent in the ear canal. \par\pard\qj \li1551\ri697\sb0\sl-260\slmult0\fi478 \up
0 \expndtw-7\charscalex100 To rule out the possibility of a perforated tympanic
membrane, \up0 \expndtw-9\charscalex100 immittance measurement is performed. A at
(type B) tympanogram, \up0 \expndtw-9\charscalex95 high values from the physica
l volume test, and an inability to obtain and \up0 \expndtw-9\charscalex95 maint
ain a hermetic seal during immittance are consistent with the \up0 \exp
ndtw-10\charscalex95 possibility of tympanic membrane perforation. \par\pard\ql
\li3635\sb0\sl-253\slmult0 \par\pard\ql\li3635\sb113\sl-253\slmult0 \up0 \expndt
w-4\charscalex100 Medical Case History \par\pard\qj \li1551\ri695\sb142\sl-260\s
lmult0\fi478 \up0 \expndtw-10\charscalex97 It is important to examine the medica
l history of the consumer to \line \up0 \expndtw-10\charscalex91 determine wheth
er cerumen management is contraindicated, for instance, \line \up0 \expndtw-9\ch
arscalex95 if (1) the tympanic membrane is perforated or patent pressure equaliz
a-\line \up0 \expndtw-10\charscalex94 tion (PE) tubes are present, (2) active ac
quired immune deciency syn-\line \up0 \expndtw-9\charscalex91 drome (AIDS) is pre
sent, and (3) dizziness or any other disease conditions \line \up0 \expndtw-9\ch
arscalex100 at any portions of the external auditory meatus (pinna, ear canal, a
nd \line \up0 \expndtw-9\charscalex94 tympanic membrane) or other conditions
such as epileptic seizures \line \up0 \expndtw-10\charscalex96 that may cau
se complications or put the consumer at risk are present. \line \up0 \expndtw-9\
charscalex97 From the medical case history the clinician determines the
most
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51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451400514
51400514514005145140051451400514514005145140051451400514514005145140051451401fff
d9}}}}}\pard\sb0\sl-240{\bkmkstart Pg181}{\bkmkend Pg181}\par\pard\li3569\sb0\sl
-241\slmult0\par\pard\li3569\sb0\sl-241\slmult0\par\pard\li3569\sb201\sl-241\slm
ult0\fi0\tx7213 \up0 \expndtw-8\charscalex92 \ul0\nosupersub\cf5\f6\fs18 Cerumen
Management\tab \up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22 161\pa
r\pard\qj \li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par
\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\p
ard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\par
d\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\
qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj
\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\l
i1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1
286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li128
6\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\
sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb
0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\

sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl

-220\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-2
20\slmult0 \par\pard\qj\li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\sb0\sl-220
\slmult0 \par\pard\qj\li1286\ri993\sb75\sl-220\slmult0\tx2354 \up0 \expndtw-7\ch
arscalex100 \ul0\nosupersub\cf5\f6\fs18 Figure 7.2 \tab \up0 \expndtw-5\charsca
lex100 Clinican, third party, and consumer view integrity of the tympanic \l
ine\up0 \expndtw-8\charscalex96 membrane with a video-otoscope. (Photo printed w
ith permission.) \par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-24
0{\bkmkstart Pg182}{\bkmkend Pg182}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\
li1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2900 \up0 \
expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 162\tab \up0 \expndtw-8\char
scalex96 \ul0\nosupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with D
isabilities\par\pard\qj \li1551\sb0\sl-240\slmult0 \par\pard\qj\li1551\ri695\sb1
06\sl-240\slmult0 \up0 \expndtw-9\charscalex94 \ul0\nosupersub\cf2\f3\fs22 appro
priate cerumen management technique for a specic individual \up0 \expndtw-1
0\charscalex94 with disabilities. \par\pard\qj \li1551\ri696\sb4\sl-260\slmult0\
fi478 \up0 \expndtw-10\charscalex88 Malignant otitis externa (Pseudomonas osteom
yelitis) is a serious and \line \up0 \expndtw-9\charscalex92 life-threatening di
sease that may develop if the ear canal is irrigated when \line \up0 \expndtw-10
\charscalex93 diabetes mellitus and immunocompromising diseases such as A
IDS \line \up0 \expndtw-10\charscalex95 are present (Ford & Courteney-Harris, 1
990; Roeser & Roland, 1992). \line \up0 \expndtw-9\charscalex100 In nondiabetic
, nonimmunocompromised, and healthy individuals, \line \up0 \expndtw-9\chars
calex94 malignant otitis externa is considered a rare occurrence. Malignant otit
is \line \up0 \expndtw-9\charscalex97 externa infection is invasive, and if left
untreated, it may lead to osteo-\line \up0 \expndtw-9\charscalex94 myelitis of
the skull base with cranial nerve paralysis (Ford & Courteney-\line \up0 \expndt
w-10\charscalex94 Harris, \up0 \expndtw-10\charscalex94 1990; Zikk, Rapoport,
Hamelfarb, \up0 \expndtw-10\charscalex94 1991). Consumers with \par\pard\qj \
li1551\ri695\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex94 diabetes mellitus
and immunocompromising disease conditions such as \up0 \expndtw-10\charscalex95
AIDS need a referral for medical treatment. \par\pard\qj \li1551\ri697\sb0\sl-26
0\slmult0\fi478 \up0 \expndtw-9\charscalex100 Cerumen management is done through
the use of (1) cerumen \line \up0 \expndtw-9\charscalex92 extraction instrumen
ts such as disposable plastic curettes (see Fig. 7.1), \par\pard\ql \li1551\sb
6\sl-253\slmult0\tx3108 \up0 \expndtw-10\charscalex92 (2) suction, and \tab \u
p0 \expndtw-10\charscalex95 (3) irrigation or lavage. From our experience
with \par\pard\qj \li1551\ri697\sb2\sl-260\slmult0 \up0 \expndtw-9\charscalex93
people who have disabilities, irrigation is much faster, more cost eective, \lin
e \up0 \expndtw-9\charscalex94 and less prone to complications if properly
done. Sometimes, when \line \up0 \expndtw-9\charscalex95 necessary, the t
hree procedures may be used in combination \line \up0 \expndtw-9\cha
rscalex93 (Ballachanda & Peers, 1992; Graber, 1986). If the cerumen is
hard \line \up0 \expndtw-6\charscalex100 before irrigation, it should be s
oftened by the clinician through \line \up0 \expndtw-9\charscalex97 applicat
ion of softening agents of choice. A list of suggested softening \line \up0 \exp
ndtw-10\charscalex90 agents is displayed in Table \up0 \expndtw-10\charscalex
91 7.2. Softening hard cerumen makes the \par\pard\qj \li1551\ri698\sb0\sl260\slmult0 \up0 \expndtw-9\charscalex93 irrigation procedure much easier an
d faster and reduces the risk of \up0 \expndtw-10\charscalex93 complicatio
ns. \par\pard\ql \li2907\sb0\sl-195\slmult0 \par\pard\ql\li2907\sb0\sl-195\slmul
t0 \par\pard\ql\li2907\sb164\sl-195\slmult0 \up0 \expndtw0\charscalex107 \ul0\no
supersub\cf7\f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 ONTRAINDICATIONS TO\ul0\nosu
persub\cf7\f8\fs24 I\ul0\nosupersub\cf31\f32\fs17 RRIGATION \par\pard\qj \li155
1\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri696\sb12\sl-260\slmult0\fi478 \up0 \e
xpndtw-10\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Contraindications to irrigat
ion are similar to some of those noted \line \up0 \expndtw-9\charscalex93 previo
usly in the section on medical case history. Aural lavage should not \line \up0
\expndtw-8\charscalex100 be used for cerumen-impacted ears of consumers with the
following \line \up0 \expndtw-10\charscalex94 conditions: \up0 \expndtw-10\char

scalex92 (1) perforated tympanic membrane, (2) patent PE tubes, \par\pard

\qj \li1551\ri696\sb0\sl-260\slmult0 \up0 \expndtw-7\charscalex100 (3) otitis ex
terna, and (4) a history of recent middle ear surgery with \line \up0 \expndtw6\charscalex100 a portion of the external auditory canal removed. Accord
ing to \line \up0 \expndtw-10\charscalex94 Graber (1986), young children and in
fants should be excluded because \line \up0 \expndtw-6\charscalex100 the tympani
c membranes of this group may be prone to perforation \line \up0 \expndtw-9\char
scalex97 as a result of lavaging. For children or consumers with PE tubes, there
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41\slmult0\par\pard\li3569\sb201\sl-241\slmult0\fi0\tx7208 \up0 \expndtw-8\chars
calex92 \ul0\nosupersub\cf5\f6\fs18 Cerumen Management\tab \up0 \expndtw-10\char
scalex92 \ul0\nosupersub\cf2\f3\fs22 163\par\pard\li1729\sb0\sl-207\slmult0\par\
pard\li1729\sb0\sl-207\slmult0\par\pard\li1729\sb0\sl-207\slmult0\par\pard\li172
9\sb0\sl-207\slmult0\par\pard\li1729\sb0\sl-207\slmult0\par\pard\li1729\sb0\sl-2
07\slmult0\par\pard\li1729\sb0\sl-207\slmult0\par\pard\li1729\sb0\sl-207\slmult0
\par\pard\li1729\sb0\sl-207\slmult0\par\pard\li1729\sb0\sl-207\slmult0\par\pard\
li1729\sb150\sl-207\slmult0\fi2335 \up0 \expndtw-4\charscalex100 \ul0\nosupersub
\cf5\f6\fs18 Table 7.1\par\pard\li1729\sb72\sl-207\slmult0\fi0 \up0 \expndtw-4\c
harscalex100 Incidence of Excessive/Impacted Cerumen on Different Populations\pa
r\pard\li1286\sb130\sl-207\slmult0\fi3792\tx6513 \up0 \expndtw-8\charscalex91 Sa
mple Size\tab \up0 \expndtw-8\charscalex91 Incidence (%)\par\pard\li1286\sb79\sl
-207\slmult0\fi0 \up0 \expndtw-8\charscalex91 Children (non^mentally retarded)\p
ar\pard\li1286\sb12\sl-207\slmult0\fi0\tx5416\tx6886 \up0 \expndtw-8\charscalex9
1 Roche et al. (1978)\tab \up0 \expndtw-8\charscalex91 224\tab \up0 \expndtw-8\c
harscalex91 10\par\pard\li1286\sb13\sl-207\slmult0\fi0\tx5414\tx6886 \up0 \expnd
tw-8\charscalex91 Bricco (1985)\tab \up0 \expndtw-8\charscalex91 349\tab \up0 \e
xpndtw-8\charscalex91 10\par\pard\li1286\sb12\sl-207\slmult0\fi0 \up0 \expndtw-8
\charscalex91 Adults (non^mentally retarded)\par\pard\li1286\sb12\sl-207\slmult0
\fi0\tx5418\tx6952 \up0 \expndtw-8\charscalex91 Lebensohn (1943)\tab \up0 \expnd
tw-8\charscalex91 794\tab \up0 \expndtw-8\charscalex91 2.5\par\pard\li1286\sb13\
sl-207\slmult0\fi0\tx5339\tx6951 \up0 \expndtw-8\charscalex91 Lebensohn (1943)\t
ab \up0 \expndtw-8\charscalex91 3258\tab \up0 \expndtw-8\charscalex91 8\par\pard
\li1286\sb12\sl-207\slmult0\fi0\tx5446\tx6888 \up0 \expndtw-8\charscalex91 Perry
(1957)\tab \up0 \expndtw-8\charscalex91 111\tab \up0 \expndtw-8\charscalex91 17
\par\pard\li1286\sb12\sl-207\slmult0\fi0\tx5411\tx6951 \up0 \expndtw-8\charscale
x91 Hopkinson (1981)\tab \up0 \expndtw-8\charscalex91 500\tab \up0 \expndtw-8\ch
arscalex91 4\par\pard\li1286\sb11\sl-207\slmult0\fi0\tx5428\tx6951 \up0 \expndtw
-8\charscalex91 Foltner (1984)\tab \up0 \expndtw-8\charscalex91 100\tab \up0 \ex
pndtw-8\charscalex91 9\par\pard\li1286\sb13\sl-207\slmult0\fi0\tx5420\tx6952 \up
0 \expndtw-8\charscalex91 Cooper (1985)\tab \up0 \expndtw-8\charscalex91 587\tab
\up0 \expndtw-8\charscalex91 5\par\pard\li1286\sb12\sl-207\slmult0\fi0 \up0 \ex
pndtw-8\charscalex91 Adolescents (mentally retarded)\par\pard\li1286\sb12\sl-207
\slmult0\fi0\tx5418\tx6867 \up0 \expndtw-8\charscalex91 Nudo (1965)\tab \up0 \ex
pndtw-8\charscalex91 494\tab \up0 \expndtw-8\charscalex91 36\par\pard\li1286\sb1
3\sl-207\slmult0\fi0\tx5439\tx6865 \up0 \expndtw-8\charscalex91 Fulton & Griffin
(1967)\tab \up0 \expndtw-8\charscalex91 191\tab \up0 \expndtw-8\charscalex91 28
\par\pard\li1286\sb12\sl-207\slmult0\fi0\tx5498\tx6867 \up0 \expndtw-8\charscale

x91 Brister et al. (1986)\tab \up0 \expndtw-8\charscalex91 88\tab \up0 \expndtw8\charscalex91 22\par\pard\li1286\sb12\sl-207\slmult0\fi0\tx5429\tx6865 \up0 \ex
pndtw-8\charscalex91 Crandell & Roeser (in press)\tab \up0 \expndtw-8\charscalex
91 121\tab \up0 \expndtw-8\charscalex91 28\par\pard\li1286\sb13\sl-207\slmult0\f
i0 \up0 \expndtw-8\charscalex91 Geriatric population (non^mentally retarded)\par
\pard\li1286\sb11\sl-207\slmult0\fi0\tx5417\tx6878 \up0 \expndtw-8\charscalex91
Mahoney (1987)\tab \up0 \expndtw-8\charscalex91 242\tab \up0 \expndtw-8\charscal
ex91 57\par\pard\li1286\sb12\sl-207\slmult0\fi0\tx5429\tx6865 \up0 \expndtw-8\ch
arscalex91 Mahoney (in press)\tab \up0 \expndtw-8\charscalex91 104\tab \up0 \exp
ndtw-8\charscalex91 34\par\pard\qj \li1286\ri1009\sb177\sl-200\slmult0 \up0 \exp
ndtw-6\charscalex97 \ul0\nosupersub\cf3\f4\fs16 From Roeser, R. J., & Roland, P.
(1992). What audiologists must know about cerumen manage\up0 \expndtw-6\charsca
lex94 ment. American Journal of Audiology, 1(4), 27^35. (Copyright by the Amer
ican-Speech-Language-\line \up0 \expndtw-7\charscalex94 Hearing Association. Rep
rinted with permission.)
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
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53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2903 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 164\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\li1750\sb0\sl-207\slmult0\par\pard\li1750\sb0\sl-207\slmult0\par\pard\li17
50\sb0\sl-207\slmult0\par\pard\li1750\sb0\sl-207\slmult0\par\pard\li1750\sb0\sl207\slmult0\par\pard\li1750\sb0\sl-207\slmult0\par\pard\li1750\sb0\sl-207\slmult
0\par\pard\li1750\sb0\sl-207\slmult0\par\pard\li1750\sb0\sl-207\slmult0\par\pard
\li1750\sb0\sl-207\slmult0\par\pard\li1750\sb0\sl-207\slmult0\par\pard\li1750\sb
0\sl-207\slmult0\par\pard\li1750\sb0\sl-207\slmult0\par\pard\li1750\sb33\sl-207\
slmult0\fi2576 \up0 \expndtw-2\charscalex100 Table 7.2\par\pard\li1750\sb72\sl-2
07\slmult0\fi0 \up0 \expndtw-2\charscalex100 Summary of CommerciallyAvailable Ce
rumenolytics and Other Products\par\pard\li1551\sb13\sl-207\slmult0\fi1977 \up0
\expndtw-8\charscalex96 Used for Softening Cerumen\par\pard\li1551\sb131\sl-207\
slmult0\fi0\tx3758\tx4834 \up0 \expndtw-8\charscalex96 Brand Name\tab \up0 \expn
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persub\cf5\f6\fs18 OTC\tab \up0 \expndtw-8\charscalex96 Carbamide peroxide (6.5%
) and glycerine\par\pard\li1551\sb12\sl-207\slmult0\fi0\tx3743\tx4834 \up0 \expn
dtw-8\charscalex96 Auro Ear Drops\tab \up0 \expndtw-8\charscalex96 OTC\tab \up0
\expndtw-8\charscalex96 Carbamide peroxide (6.5%) and glycerine\par\pard\li1551\
sb13\sl-207\slmult0\fi0\tx3743\tx4834 \up0 \expndtw-8\charscalex96 Bausch & Lomb
\tab \up0 \expndtw-8\charscalex96 OTC\tab \up0 \expndtw-8\charscalex96 Carbamide
peroxide (6.5%) and glycerine\par\pard\li1551\sb11\sl-207\slmult0\fi0\tx3813\tx
4834 \up0 \expndtw-8\charscalex96 Cerumenex Drops\tab \up0 \expndtw-8\charscalex
96 Rx\tab \up0 \expndtw-8\charscalex96 Triethanolamine\par\pard\li1551\sb12\sl-2
07\slmult0\fi3282 \up0 \expndtw-8\charscalex94 Polypeptide\par\pard\li1551\sb13\
sl-207\slmult0\fi3282 \up0 \expndtw-8\charscalex94 Oleate condensate\par\pard\li
1551\sb12\sl-207\slmult0\fi0\tx3743\tx4834 \up0 \expndtw-8\charscalex94 Debrox\t
ab \up0 \expndtw-8\charscalex94 OTC\tab \up0 \expndtw-8\charscalex94 Carbamide p
eroxide (6.5%) and glycerine\par\pard\li1551\sb12\sl-207\slmult0\fi0\tx3743\tx48
34 \up0 \expndtw-8\charscalex94 Murine Ear Drops\tab \up0 \expndtw-8\charscalex9
4 OTC\tab \up0 \expndtw-8\charscalex94 Carbamide peroxide (6.5%) and glycerine\p
ar\pard\qj \li1551\ri745\sb171\sl-200\slmult0 \up0 \expndtw-6\charscalex95 \ul0\
nosupersub\cf3\f4\fs16 Other products for softening cerumen include baby oil, Co
lace liquid (docusate sodium), hydrogen \up0 \expndtw-7\charscalex95 peroxide (3
%), mineral oil, sodium bicarbonate, and virgin olive oil. \par\pard\ql \li1551\
sb14\sl-184\slmult0 \up0 \expndtw-7\charscalex100 \ul0\super\cf45\f46\fs16 a\ul0
\nosupersub\cf3\f4\fs16 Distributed only through audiologists. \par\pard\ql \li1
551\sb16\sl-184\slmult0 \up0 \expndtw-6\charscalex100 OTC, over-the-counter; Rx,
prescription. \par\pard\qj \li1551\ri745\sb3\sl-200\slmult0 \up0 \expndtw-6\cha
rscalex97 From Roeser, R. J., & Roland, P. (1992). What audiologists must know a
bout cerumen manage\up0 \expndtw-6\charscalex94 ment. American Journal of Audiol
ogy, 1(4), 27^35. (Copyright by the American-Speech-Language-\line \up0 \expnd
tw-7\charscalex94 Hearing Association. Reprinted with permission.)
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}}
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{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
185}{\bkmkend Pg185}\par\pard\li3569\sb0\sl-241\slmult0\par\pard\li3569\sb0\sl-2
41\slmult0\par\pard\li3569\sb201\sl-241\slmult0\fi0\tx7203 \up0 \expndtw-8\chars
calex92 \ul0\nosupersub\cf5\f6\fs18 Cerumen Management\tab \up0 \expndtw-10\char
scalex92 \ul0\nosupersub\cf2\f3\fs22 165\par\pard\ql \li1286\sb0\sl-253\slmult0
\par\pard\ql\li1286\sb55\sl-253\slmult0\tx4475 \up0 \expndtw-5\charscalex100 is
the risk of displacing the tubes \tab \up0 \expndtw-10\charscalex97 (Harkess, 19
82). During irrigation, \par\pard\qj \li1286\ri959\sb0\sl-260\slmult0 \up0 \expn
dtw-9\charscalex95 cerumen could be forced through patent PE tubes or a
perforated \line \up0 \expndtw-8\charscalex100 tympanic membrane to the middle
ear cavity with the attendant risks \line \up0 \expndtw-9\charscalex100 of intr
oducing infection (Zivic & King, 1993) into the middle ear cavity. \line \up0 \e
xpndtw-9\charscalex95 Otitis externa, if present, can be aggravated by ir
rigation water and \line \up0 \expndtw-10\charscalex82 pressure. \par\pard\ql \l
i2979\sb0\sl-207\slmult0 \par\pard\ql\li2979\sb0\sl-207\slmult0 \par\pard\ql\li2
979\sb132\sl-207\slmult0 \up0 \expndtw0\charscalex104 \ul0\nosupersub\cf7\f8\fs2
4 S\ul0\nosupersub\cf31\f32\fs17 OFTENING OF THE\ul0\nosupersub\cf7\f8\fs24 C\u
l0\nosupersub\cf31\f32\fs17 ERUMEN \par\pard\qj \li1286\sb0\sl-260\slmult0 \par\
pard\qj\li1286\ri961\sb10\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 \ul
0\nosupersub\cf2\f3\fs22 It is our practice to recommend the use of a cerumenoly
tic agent to \up0 \expndtw-9\charscalex96 soften hard cerumen for 4 ^5 days befo
re irrigation. Softening the ceru\up0 \expndtw-9\charscalex94 men is important,
because it reduces the possibility of using instruments \up0 \expndtw-9\charscal
ex93 to forcibly extract hard cerumen from the ear canal walls. This can cause \

up0 \expndtw-10\charscalex96 a sheering of the skin, damage to the underlying ti

ssues, and pain and \up0 \expndtw-10\charscalex93 bleeding for the consumer. \pa
r\pard\ql \li1764\sb6\sl-253\slmult0\tx3458 \up0 \expndtw-10\charscalex96 Over-t
he-counter \tab \up0 \expndtw-6\charscalex100 (OTC) cerumenolytics that are
frequently \par\pard\qj \li1286\ri959\sb3\sl-259\slmult0 \up0 \expndtw-10\charsc
alex96 used include Audiologists Choice, Debrox, and Murine Ear Drops. The \line
\up0 \expndtw-10\charscalex96 chemical compositions of these cerumenolytics are
similar: carbamide \line \up0 \expndtw-9\charscalex93 peroxide (6.5%) and glyce
rine. Of course, other softening agents such as \line \up0 \expndtw-8\charscalex
100 baby, mineral, or olive oil; Auro Ear Drops; or hydrogen peroxide are \line
\up0 \expndtw-10\charscalex95 also used by some clinicians. Whether Audiologists
Choice, Debrox, or \line \up0 \expndtw-10\charscalex96 Murine Ear Drops are use
d, the carbamide peroxide chemical element \line \up0 \expndtw-7\charscalex100 b
reaks down the cerumen, and the glycerin softens it for removal. If \line \up0 \
expndtw-9\charscalex93 hydrogen peroxide alone is used, there is a tendency for
chunks or large, \line \up0 \expndtw-9\charscalex93 dry particles of cerumen, so
me of which are still attached to the ear canal \line \up0 \expndtw-6\charscalex
100 walls, to be left behind. Although the eervescence of the hydrogen \line \up0
\expndtw-10\charscalex96 peroxide breaks down the hard cerumen, it lacks any oi
ly substance to \line \up0 \expndtw-9\charscalex96 soften it to facilitate the n
atural self-cleansing process or ease removal \line \up0 \expndtw-9\charscalex93
by irrigation or lavaging. Before lavaging, consumers, caregivers, or \
line \up0 \expndtw-9\charscalex95 signicant others are instructed to apply a
few drops (5 to 8 or as \line \up0 \expndtw-6\charscalex100 indicated in t
he instructions) of the cerumenolytic agent twice daily \line \up0 \expndtw-10\
charscalex96 for about 4 ^5 days. The ease of softening of the cerumen depends o
n \line \up0 \expndtw-10\charscalex94 the degree of hardness and the depth or qu
antity of cerumen impaction. \line \up0 \expndtw-7\charscalex100 If the cerumen
is extremely hard and deep in the canal, a few more \line \up0 \expndtw-8\charsc
alex100 days of application of the cerumenolytic agent may be required for it \l
ine \up0 \expndtw-9\charscalex97 to be eective. Some consumers have reporte
d that their hearing \line \up0 \expndtw-9\charscalex94 became worse after
a few days of application of the cerumenolytic
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
186}{\bkmkend Pg186}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2903 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 166\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-257\slmult0 \par\pard\qj\li1551\ri695\sb75\sl-257\slmult
0 \up0 \expndtw-9\charscalex92 \ul0\nosupersub\cf2\f3\fs22 agent. This is normal
, because in the process of softening of the cerumen \line \up0 \expndtw-10\char
scalex94 some of the matter loosened as a result and closed minute air openings
\line \up0 \expndtw-10\charscalex93 that are sometimes present in a cerumen-impa
cted ear and allow sound \line \up0 \expndtw-9\charscalex97 to pass. Once these
tiny air pores or ventilation are closed because of \line \up0 \expndtw-9\charsc
alex96 the spread of loosened and falling cerumen particles, hearing is signi-\li
ne \up0 \expndtw-9\charscalex97 cantly aected. However, with the continued
use of the softening \line \up0 \expndtw-9\charscalex92 agent, the air vents
open again as the cerumen becomes further softened \line \up0 \expndtw-10\charsc

alex89 and loosened. \par\pard\ql \li2565\sb0\sl-207\slmult0 \par\pard\ql\li2565

\sb0\sl-207\slmult0 \par\pard\ql\li2565\sb151\sl-207\slmult0 \up0 \expndtw0\char
scalex108 \ul0\nosupersub\cf7\f8\fs24 I\ul0\nosupersub\cf31\f32\fs17 RRIGATION O
F THE\ul0\nosupersub\cf7\f8\fs24 E\ul0\nosupersub\cf31\f32\fs17 XTERNAL\ul0\nos
upersub\cf7\f8\fs24 E\ul0\nosupersub\cf31\f32\fs17 AR\ul0\nosupersub\cf7\f8\fs2
4 C\ul0\nosupersub\cf31\f32\fs17 ANAL \par\pard\qj \li1551\sb0\sl-258\slmult0 \
par\pard\qj\li1551\ri694\sb13\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex94
\ul0\nosupersub\cf2\f3\fs22 Once the impacted cerumen has been softened,
it and other \line \up0 \expndtw-8\charscalex100 debris can usually be ushed o
ut without di\u8260?culties. It is essential that \line \up0 \expndtw-10\charsca
lex94 the ear canal be viewed with a video-otoscope or a hand-held otoscope \lin
e \up0 \expndtw-9\charscalex98 (whichever is available) before lavaging. Also, t
he integrity of the tym-\line \up0 \expndtw-10\charscalex96 panic membrane must
be ascertained before lavaging. Tympanometry \line \up0 \expndtw-10\charscalex96
should be performed to objectively conrm tympanic membrane integ-\line \up0 \exp
ndtw-9\charscalex95 rity. A cerumen-impacted ear canal can be partially opened w
ith the use \line \up0 \expndtw-9\charscalex95 of a curette to create ventilatio
n to the TM, permitting successful tympa-\line \up0 \expndtw-10\charscalex91 nom
etric assessment (Manning, 1992). Tympanometric ndings that yield \line \up0 \exp
ndtw-9\charscalex92 an usually large canal volume exceeding 1.5 mm suggest the p
ossibility of \line \up0 \expndtw-10\charscalex94 a perforated tympanic membrane
. To remove cerumen, a few items are \line \up0 \expndtw-9\charscalex93 needed:
(1) a Water Pik; (2) a kidney-shaped basin; (3) a plastic apron or \line \up0 \e
xpndtw-9\charscalex94 cover (water repellant) for the consumer, assistant, and c
linician; (4) dis-\line \up0 \expndtw-9\charscalex90 posable plastic curettes; (
5) paper towels; and (6i) forceps.Water should be \line \up0 \expndtw-10\charsca
lex90 kept at body temperature (37 C). \par\pard\qj \li1551\ri696\sb1\sl-260\slm
ult0\fi478 \up0 \expndtw-10\charscalex95 A Water Pik is chosen rather than an ea
r syringe for two reasons. \line \up0 \expndtw-8\charscalex100 First, the ear ir
rigator that attaches to the Water Pik is long and more \line \up0 \expndtw-9\ch
arscalex92 exible, and the nozzle is easier to direct to the roof of the ear cana
l walls. \line \up0 \expndtw-9\charscalex97 Second, the irrigator can provide a
constant stream of water at slow or \line \up0 \expndtw-9\charscalex100 fast pul
sating pressure that can be controlled. On the other hand, the \line \up0 \expnd
tw-9\charscalex95 pressure produced by an ear syringe is more variable, the inst
rument is \line \up0 \expndtw-7\charscalex100 relatively large, and it is fairly
di\u8260?cult to match the exibility oered by \line \up0 \expndtw-10\charscalex97
an ear irrigator, especially when one is performing the procedure on a \line \u
p0 \expndtw-9\charscalex95 consumer with athetosis or one who is very spastic wi
th his or her head \line \up0 \expndtw-6\charscalex100 permanently tilted close
to the shoulder, leaving little or no room in \line \up0 \expndtw-8\charscalex10
0 which to work. As a result of the attributes stated above, a Water Pik
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
187}{\bkmkend Pg187}\par\pard\li3569\sb0\sl-241\slmult0\par\pard\li3569\sb0\sl-2
41\slmult0\par\pard\li3569\sb201\sl-241\slmult0\fi0\tx7210 \up0 \expndtw-8\chars
calex92 \ul0\nosupersub\cf5\f6\fs18 Cerumen Management\tab \up0 \expndtw-10\char
scalex92 \ul0\nosupersub\cf2\f3\fs22 167\par\pard\ql \li1286\sb0\sl-253\slmult0
\par\pard\ql\li1286\sb55\sl-253\slmult0\tx3780\tx4584\tx7038 \up0 \expndtw-10\ch
arscalex97 is recommended for use \tab \up0 \expndtw-10\charscalex87 (Larsen,

\tab \up0 \expndtw-10\charscalex96 1976; Roeser & Roland, \tab \up0 \expndtw
-10\charscalex78 1983). \par\pard\qj \li1286\ri960\sb0\sl-260\slmult0 \up0 \expn
dtw-9\charscalex94 The procedure is explained to the consumer and the ac
companying \up0 \expndtw-10\charscalex92 caregiver or family member. Some consum
ers may be unable to compre\up0 \expndtw-10\charscalex95 hend the instructions g
iven because of the degree of mental deciency \up0 \expndtw-9\charscalex100 or, i
f they do understand, are unable to follow commands because of \up0 \expndtw-10\
charscalex93 neuromotor decits. \par\pard\qj \li1286\ri959\sb0\sl-259\slmult0\fi4
78 \up0 \expndtw-10\charscalex97 Once the consumer is comfortably seated, the Wa
ter Pik is lled \line \up0 \expndtw-10\charscalex96 with lukewarm water or body t
emperature water kept at 37 C. The use \line \up0 \expndtw-9\charscalex93 of col
d or hot water to lavage the ear canal can stimulate the semicircular \line \up0
\expndtw-9\charscalex94 canals, which may provoke the vestibular reex, ca
using dizziness, \line \up0 \expndtw-10\charscalex94 nausea, and vomiting (Roes
er & Roland, 1992; Zivic & King, 1993). The \line \up0 \expndtw-5\charscalex100
irrigating nozzle is placed in the ear canal while the pinna is pulled \line \up
0 \expndtw-10\charscalex94 upward and backward to straighten the canal. The stre
am of water from \line \up0 \expndtw-8\charscalex100 the irrigation nozzle is di
rected to the posterior walls of the roof of the \line \up0 \expndtw-9\charscale
x95 ear canal to the right and then to the left until su\u8260?cient pressure ha
s built \line \up0 \expndtw-10\charscalex97 up behind the cerumen plug to ush it
out. Unlike with an ear syringe, \line \up0 \expndtw-9\charscalex96 it is easy t
o pull out the nozzle if the consumer is experiencing tremors. \line \up0 \expnd
tw-9\charscalex100 It is not advisable to direct the stream of water at the ceru
men for two \line \up0 \expndtw-9\charscalex93 reasons. First, the pressure can
force the cerumen deeper into the canal. \line \up0 \expndtw-10\charscalex93 Sec
ond, if the cerumen was already very loose, the tympanic membrane \line \up0 \ex
pndtw-9\charscalex98 may be exposed to a direct hit from the water str
eam. This can \line \up0 \expndtw-9\charscalex92 cause serious damage. Theref
ore the water stream is directed at the \line \up0 \expndtw-9\charscalex9
3 roof of the canal in a steady state with the goal of gaining acce
ss \line \up0 \expndtw-9\charscalex94 of ow behind the cerumen and debris.
Once this is achieved, the \line \up0 \expndtw-8\charscalex100 cerumen is us
hed out. The ear canal is checked periodically with a \line \up0 \expndtw-9\char
scalex93 video-otoscope or hand-held otoscope to determine the eectiveness
\line \up0 \expndtw-9\charscalex91 of the lavaging process. Consumers are alway
s excited to see the\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub
\cf2\f3\fs22 inside\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \line \up0 \expn
dtw-9\charscalex93 \ul0\nosupersub\cf2\f3\fs22 of their ears while the procedure
is in progress. Small chunks of cerumen \line \up0 \expndtw-8\charscalex100 can
be removed, with a disposable plastic curette. The use of plastic \line \up0 \e
xpndtw-9\charscalex97 curettes rather than the metallic type is preferable. If t
here is a sudden \line \up0 \expndtw-9\charscalex100 jerk or uncontrolled body m
ovements by the consumer while lavaging \line \up0 \expndtw-9\charscalex93 is i
n progress, the risk of physical injury is less severe with use of \l
ine \up0 \expndtw-10\charscalex87 disposable plastic curettes. \par\pard\qj \li1
286\ri961\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 Lavaging contin
ues until the tympanic membrane becomes visible. \line \up0 \expndtw-10\charscal
ex95 The water stream, pressure, and ow should be reduced at this time to \line \
up0 \expndtw-9\charscalex92 avoid accidental physical insult to the tympanic mem
brane. The ear canal \line \up0 \expndtw-10\charscalex96 is examined again with
an otoscope to ensure that the tympanic mem-\line \up0 \expndtw-10\charscalex97
brane is intact. Again, this can be achieved objectively by performing
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scalex96 \ul0\nosupersub\cf2\f3\fs22 168\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Audiologic Rehabilitation for People with Disabilities\par
\pard\qj \li1551\sb0\sl-255\slmult0 \par\pard\qj\li1551\ri696\sb79\sl-255\slmult
0 \up0 \expndtw-9\charscalex91 \ul0\nosupersub\cf2\f3\fs22 tympanometry. The ear
canal should be checked to ensure that there is no \up0 \expndtw-9\charscalex10
0 bleeding and the canal is free of excessive cerumen and debris. The \up0 \exp
ndtw-10\charscalex97 ear canal is then dried by an applicator moistened with 70%
isopropyl \up0 \expndtw-9\charscalex92 alcohol. The clinician must ensure that
there is no bleeding before alcohol \up0 \expndtw-10\charscalex92 solution is ap
plied. \par\pard\ql \li3842\sb0\sl-276\slmult0 \par\pard\ql\li3842\sb232\sl-276\
slmult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 REFERENCES \pa
r\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb100\sl-207\slmult0\fi0\tx4948
\up0 \expndtw-8\charscalex94 \ul0\nosupersub\cf5\f6\fs18 Adams, G., Boies, L
., & Papparella, M.\tab \up0 \expndtw-8\charscalex94 (1978). Fundamentals o
f Otolaryngology.\par\pard\li1551\sb13\sl-207\slmult0\fi239 \up0 \expndtw-8\cha
rscalex94 Philadelphia: WB Saunders.\par\pard\qj \li1551\ri730\sb0\sl-220\slmult
0\tx1790 \up0 \expndtw-7\charscalex93 Ballachanda, B. B., & Peers, C. J. (1992,
February). Cerumen management: Instruments \line\tab \up0 \expndtw-8\charscalex9
0 and procedures. ASHA, 34, 43 ^ 46. \par\pard\qj \li1551\ri729\sb0\sl-220\slmul
t0\tx1790 \up0 \expndtw-7\charscalex100 Bricco, E. (1985). Impacted cerumen as a
reason for failure in hearing; Conservation \line\tab \up0 \expndtw-8\charscale
x85 programs. Journal of School Health, 55, 240 ^241. \par\pard\ql \li1551\ri728
\sb0\sl-220\slmult0\tx1790\tx1790 \up0 \expndtw-7\charscalex96 Brister, F., Full
wood, H. L., Ripp,T., & Blodgett, C. (1986). Prevalence of occlusion due \line\t
ab \up0 \expndtw-7\charscalex91 to impacted cerumen among mentally retarded adol
escents. AmericanJournal of Mental \line \tab \up0 \expndtw-8\charscalex85 Decien
cy, 91, 302^304. \par\pard\ql \li1551\ri729\sb0\sl-220\slmult0\tx1790\tx1790 \up
0 \expndtw-7\charscalex98 Crandell, C. C., & Roeser, R. J. (1993). Incidence of
excessive/impacted cerumen in \line\tab \up0 \expndtw-7\charscalex89 mentally r
etarded individuals. American Journal of Mental Retardation, 97, 568 ^574. \line
\up0 \expndtw-7\charscalex97 Ford, G. R., & Courteney-Harris, R. G. (199
0). Another hazard of ear syringing: \line\tab \up0 \expndtw-7\charscalex89 M
alignant external otitis.The Journal of Laryngology and Otology, 104, 709 ^710.
\line \up0 \expndtw-8\charscalex89 Fulton, R., & Gri\u8260?n, C. \up0 \expnd
tw-8\charscalex89 (1967). Audiological-otological considerations with the \p
ar\pard\ql \li1790\sb1\sl-192\slmult0 \up0 \expndtw-8\charscalex89 mentally reta
rded. Mental Retardation, 5(3), 26 ^31. \par\pard\ql \li1551\sb16\sl-207\slmult0
\up0 \expndtw-7\charscalex91 Graber, R. F. (1986). Removing impacted cerumen. P
atient Care, 20, 151^153. \par\pard\qj \li1551\ri728\sb3\sl-220\slmult0\tx1790 \
up0 \expndtw-7\charscalex95 Harkess, C. K. (1982, January^February). Clearing th
e occluded canal. Pediatric Nurse, \line\tab \up0 \expndtw-8\charscalex87 23 ^25
. \par\pard\qj \li1551\ri729\sb0\sl-220\slmult0\tx1790 \up0 \expndtw-7\charscale
x95 Kirkwood, D. H. (1993). The cerumen management debated: Whose responsibility
is it? \line\tab \up0 \expndtw-8\charscalex84 The Hearing Journal, 46, 13 ^22.
\par\pard\qj \li1551\ri729\sb0\sl-220\slmult0\tx1790 \up0 \expndtw-7\charscalex9
2 Larsen, G. (1976). Removing cerumen with a Water Pik. American Journal of Nurs
ing, 76, \line\tab \up0 \expndtw-8\charscalex88 264 ^265. \par\pard\qj \li1551\r
i730\sb0\sl-220\slmult0\tx1790 \up0 \expndtw-7\charscalex95 Manning, R. (1992).
Cerumen management. Lexington, KY: Eastern Kentucky Speech \line\tab \up0 \expn
dtw-8\charscalex95 and Hearing Clinic. \par\pard\li1551\sb18\sl-207\slmult0\fi0\
tx4026\tx6163 \up0 \expndtw-6\charscalex100 Northern, J., & Downs, M.\tab \u
p0 \expndtw-8\charscalex90 (1984). Hearing in children\tab \up0 \expndtw-6\c
harscalex100 (3rd ed.). Baltimore:\par\pard\li1551\sb12\sl-207\slmult0\fi239 \

up0 \expndtw-6\charscalex100 W|lliam & W|lkins.\par\pard\ql \li1551\ri729\sb0\sl

-217\slmult0\tx1790\tx1790\tx1790\tx1790\tx1790 \up0 \expndtw-7\charscalex96 Nud
o, L. (1965). Comparison by age of audiological and otological ndings
in a \line\tab \up0 \expndtw-7\charscalex100 state residential institution f
or the mentally retarded: A preliminary report. In \line \tab \up0 \expndt
w-7\charscalex86 Loyd, L., & Frisina, R. (Eds.). Audiological assessment of the
mentally retarded: Proceedings \line \tab \up0 \expndtw-7\charscalex89 of nation
al conference. Parsons, KS: Parsons State Hospital and Training Center. \line \u
p0 \expndtw-7\charscalex93 Oyiborhoro, J. M. A. (1993, April). Impacted cerume
n in cerebral palsy population. Paper \line\tab \up0 \expndtw-8\charscalex96 pre
sented to The American Academy of Audiology, Phoenix, Arizona. \line \up0 \expnd
tw-7\charscalex95 Roeser, R. J., & Roland, P. (1992). What audiologists
must know about cerumen \line\tab \up0 \expndtw-8\charscalex86 management. Am
erican Journal of Audiology, 1, 27^35.
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41\slmult0\par\pard\li3569\sb201\sl-241\slmult0\fi0\tx7206 \up0 \expndtw-8\chars
calex92 \ul0\nosupersub\cf5\f6\fs18 Cerumen Management\tab \up0 \expndtw-10\char
scalex92 \ul0\nosupersub\cf2\f3\fs22 169\par\pard\qj \li1286\sb0\sl-220\slmult0
\par\pard\qj\li1286\ri993\sb75\sl-220\slmult0\tx1525 \up0 \expndtw-7\charscalex9
3 \ul0\nosupersub\cf5\f6\fs18 Ruby, R. F. (1986). Conductive hearing loss in the
elderly. Journal of Otolaryngology, 15, \line\tab \up0 \expndtw-8\charscalex84
245 ^247. \par\pard\ql \li1286\sb1\sl-195\slmult0 \up0 \expndtw-8\charscalex89 S
erra, A. (1982). Ear syringing. Nursing Mirror, 155, 10 ^12. \par\pard\qj \li128
6\ri993\sb5\sl-220\slmult0\tx1525 \up0 \expndtw-5\charscalex100 Stone, M., & Ful
ghum, R. S. (1984). Bactericidal activity of wet cerumen. Annals of \line\tab \u
p0 \expndtw-8\charscalex83 Otology, Rhinology, and Laryngology, 93, 183 ^186. \p
ar\pard\ql \li1286\ri994\sb0\sl-220\slmult0\tx1525\tx1525 \up0 \expndtw-7\charsc
alex97 Zikk, D., Rapoport,Y., & Hamelfarb, M. Z. (1991). Invasive external otiti
s after removal \line\tab \up0 \expndtw-7\charscalex90 of impacted cerumen by ir
rigation. New England Journal of Medicine, 325, 969 ^970. \line \up0 \expndtw-7\
charscalex96 Zivic, R. C., & King, S. (1993). Cerumen impaction management for c
lients of all ages. \line\tab \up0 \expndtw-8\charscalex82 Nurse Practitioner, 1
8, 29 ^37. \par\pard\ql \li3064\sb0\sl-276\slmult0 \par\pard\ql\li3064\sb238\sl276\slmult0 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 SELECTED RE
ADINGS \par\pard\qj \li1286\sb0\sl-220\slmult0 \par\pard\qj\li1286\ri994\sb51\sl
-220\slmult0\tx1525 \up0 \expndtw-7\charscalex97 \ul0\nosupersub\cf5\f6\fs18 Bai
ly, B. J. (1983). Impacted ear wax and water pick instrument. Journal of Medici
ne, \line\tab \up0 \expndtw-8\charscalex84 250,1456. \par\pard\ql \li1286\sb11\s
l-207\slmult0 \up0 \expndtw-7\charscalex89 Seiler, E. R. (1980). Ear syringing.
British Medical Journal, 280, 1273.
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b0\sl-240{\bkmkstart Pg193}{\bkmkend Pg193}\par\pard\ql \li3339\sb0\sl-368\slmul
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\par\pard\ql\li3339\sb212\sl-368\slmult0 \up0 \expndtw0\charscalex114 \ul0\nosu
persub\cf28\f29\fs32 CHAPTER 8 \par\pard\ql \li1934\sb0\sl-368\slmult0 \par\pard
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\slmult0 \par\pard\ql\li3228\sb94\sl-253\slmult0 \up0 \expndtw-3\charscalex100 \
ul0\nosupersub\cf2\f3\fs22 Kenneth C. Pugh, Ph.D. \par\pard\ql \li2581\ri2273\sb
0\sl-240\slmult0\tx3009\tx3147\tx3805 \up0 \expndtw-8\charscalex100 \ul0\nosuper
sub\cf6\f7\fs20 Division of Speech Pathology and Audiology \line\tab \up0 \expnd
tw-9\charscalex100 John A. Burns School of Medicine \line \tab \up0 \expndtw-7\c
harscalex100 University of Hawaii at Manoa \line \tab \up0 \expndtw-7\charscalex
100 Honolulu, HA \par\pard\ql \li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb0
\sl-230\slmult0 \par\pard\ql\li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb0\s
l-230\slmult0 \par\pard\ql\li2840\sb0\sl-230\slmult0 \par\pard\ql\li2840\sb97\sl
-230\slmult0 \up0 \expndtw0\charscalex107 Amplification \par\pard\qj \li3319\ri3
084\sb6\sl-260\slmult0 \up0 \expndtw-9\charscalex95 Hearing Instrument Styles \l
ine \up0 \expndtw-9\charscalex96 Hearing Aid Circuits \par\pard\ql \li3319\ri158
0\sb17\sl-240\slmult0 \up0 \expndtw-9\charscalex95 Selection, Fitting, and Verif
ication of Hearing \up0 \expndtw-9\charscalex96 Instruments \par\pard\ql \li3319
\sb29\sl-230\slmult0 \up0 \expndtw-9\charscalex96 Troubleshooting Hearing Instru
ments \par\pard\qj \li2840\ri1331\sb6\sl-260\slmult0\fi478 \up0 \expndtw-9\chars
calex93 Hearing Instruments versus AssistiveTechnology \up0 \expndtw-9\charscale

x94 Assistive Technology \par\pard\ql \li3319\sb5\sl-230\slmult0 \up0 \expndtw-7

\charscalex100 Enhancing Listening Ability \par\pard\qj \li3319\ri1387\sb6\sl-26
0\slmult0 \up0 \expndtw-9\charscalex100 Capitalizing on Modalities Other Than He
aring \up0 \expndtw-9\charscalex93 Selecting AssistiveTechnology \par\pard\qj \l
i2840\ri1352\sb0\sl-260\slmult0 \up0 \expndtw-3\charscalex100 Trends in Amplific
ation and Assistive Technology \up0 \expndtw-4\charscalex100 Conclusions \par\pa
rd\qj \li2840\ri3996\sb0\sl-260\slmult0 \up0 \expndtw-1\charscalex100 Acknowledg
ments \up0 \expndtw-8\charscalex100 References \par\pard\qj \li1286\sb0\sl-266\s
lmult0 \par\pard\qj\li1286\sb0\sl-266\slmult0 \par\pard\qj\li1286\ri960\sb64\sl266\slmult0\fi478 \up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\f3\fs22 This
chapter provides information on amplication and assistive \line \up0 \expndtw-9\
charscalex96 technology. The focus is on currently available amplication in the f
orm \line \up0 \expndtw-9\charscalex92 of hearing instruments and assistive tech
nology that can be used to either \line \up0 \expndtw-9\charscalex92 enhance lis
tening ability or capitalize on modalities other than hearing. \par\pard\ql \li4
280\sb0\sl-207\slmult0 \par\pard\ql\li4280\sb56\sl-207\slmult0 \up0 \expndtw-8\c
harscalex79 \ul0\nosupersub\cf5\f6\fs18 173 \par\pard\qj \li3067\ri2882\sb0\sl-1
60\slmult0\fi65 \up0 \expndtw0\charscalex100 \ul0\nosupersub\cf30\f31\fs12 Aural
Rehabilitation for People with Disabilities \line \up0 \expndtw0\charscalex100
Copyright \up0 \expndtw-2\charscalex100 2005, Elsevier Inc. All rights reserved.
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
194}{\bkmkend Pg194}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2645 \up0 \expndtw-10\char
scalex96 \ul0\nosupersub\cf2\f3\fs22 174\tab \up0 \expndtw-8\charscalex96 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri696\sb70\sl-260\slmu
lt0 \up0 \expndtw-9\charscalex93 \ul0\nosupersub\cf2\f3\fs22 Selection, tting gui
delines, and the rationale for providing these systems \up0 \expndtw-10\charscal
ex93 as a component of the rehabilitation process are included. \par\pard\ql \li
3676\sb0\sl-276\slmult0 \par\pard\ql\li3676\sb0\sl-276\slmult0 \par\pard\ql\li36
76\sb115\sl-276\slmult0 \up0 \expndtw0\charscalex104 \ul0\nosupersub\cf7\f8\fs24
AMPLIFICATION \par\pard\qj \li1551\ri694\sb256\sl-262\slmult0\fi478 \up0 \expnd
tw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 Rehabilitative intervention use
d to assist persons with sensory \line \up0 \expndtw-7\charscalex100 disabi
lity resulting from hearing impairment typically occurs through \line \up0 \expn
dtw-9\charscalex100 the provision of amplication. The principle role of amplicatio

n in the \line \up0 \expndtw-9\charscalex93 form of hearing instruments (hearing

aids) is to increase sounds to levels \line \up0 \expndtw-10\charscalex91 such
that persons with hearing impairment can both detect and make use \line \up0 \ex
pndtw-9\charscalex94 of the auditory signals. The use of hearing instruments dat
es back to the \line \up0 \expndtw-9\charscalex94 nineteenth century, when amplic
ation was initially achieved by cupping \line \up0 \expndtw-7\charscalex100 the
hand behind the ear a practice still used today or with dierent \line \up0 \e
xpndtw-9\charscalex91 types of ear horns and ear trumpets (Berger, 1984; Lybarge
r, 1988). Since \line \up0 \expndtw-9\charscalex93 that time, successive advance
ments have led to the production of carbon \line \up0 \expndtw-10\charscalex95 h
earing instruments, vacuum tube hearing instruments, transistor hear-\line \up0
\expndtw-9\charscalex94 ing instruments, and integrated circuit hearing instrume
nts (Dillon, 2001; \line \up0 \expndtw-9\charscalex91 Vonlanthen, 2000). Each st
age of development is sequential, which means \line \up0 \expndtw-10\charscalex9
5 that smaller and smaller hearing instruments are being produced to the \line \
up0 \expndtw-9\charscalex95 point where the amplication device could be worn at e
ar level or within \line \up0 \expndtw-10\charscalex88 the ear canal. \par\pard\
ql \li3186\sb0\sl-207\slmult0 \par\pard\ql\li3186\sb0\sl-207\slmult0 \par\pard\q
l\li3186\sb150\sl-207\slmult0 \up0 \expndtw0\charscalex104 \ul0\nosupersub\cf7\f
8\fs24 H\ul0\nosupersub\cf31\f32\fs17 EARING\ul0\nosupersub\cf7\f8\fs24 I\ul0\n
osupersub\cf31\f32\fs17 NSTRUMENT\ul0\nosupersub\cf7\f8\fs24 S\ul0\nosupersub\c
f31\f32\fs17 TYLES \par\pard\qj \li1551\sb0\sl-262\slmult0 \par\pard\qj\li1551\r
i694\sb6\sl-262\slmult0\fi478 \up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\
f3\fs22 Existing amplication options include hearing aid styles such as \line \up
0 \expndtw-7\charscalex100 body style, behind the ear (BTE), in the ear (ITE), i
n the canal (ITC), \line \up0 \expndtw-9\charscalex94 and completely in the cana
l (CIC) instruments. Body style devices repre-\line \up0 \expndtw-9\charscalex93
sent an older form of electronic hearing instrument and serve as a means \line
\up0 \expndtw-9\charscalex100 of amplication when nothing else will provide
enough power. A \line \up0 \expndtw-8\charscalex100 receiver is connected to
the hearing aid with a cord, and this hearing \line \up0 \expndtw-7\charscalex1
00 aid is usually worn in a shirt pocket or clipped to clothing. Body style \lin
e \up0 \expndtw-9\charscalex92 hearing aids provide amplication for extremely sev
ere hearing loss, for a \line \up0 \expndtw-9\charscalex98 bedridden patient, or
for an individual who may have di\u8260?culty using the \line \up0 \expndtw-9\c
harscalex100 controls of a smaller ear level hearing instrument because of reduc
ed \line \up0 \expndtw-9\charscalex96 dexterity. However, body style hearing
instruments are considered
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calex94 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \u
p0 \expndtw-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 175\par\pard\ql \li1286\
sb0\sl-258\slmult0 \par\pard\ql\li1286\ri959\sb45\sl-258\slmult0\tx1764 \up0 \ex
pndtw-10\charscalex93 cosmetically less appealing and cumbersome because of thei
r large size \line \up0 \expndtw-10\charscalex92 and cords, and as a result, thi
s hearing instrument is not often used. \line\tab \up0 \expndtw-10\charscalex95
A BTE-style hearing instrument is shown in Fig. 8.1. As the name \line \up0 \exp
ndtw-8\charscalex100 implies, components of the hearing instrument are held in t

he casing \line \up0 \expndtw-9\charscalex95 positioned behind the ear, and soun
d travels through the hearing instru-\line \up0 \expndtw-6\charscalex100 ment in
to an earmold and nally into the ear canal. The BTE-style \line \up0 \expndtw-4\
charscalex100 hearing instrument can be used by people of all ages with mild to
\line \up0 \expndtw-7\charscalex100 profound hearing loss. Because of the growth
changes that occur in \line \up0 \expndtw-9\charscalex94 young children, BTE-s
tyle hearing instruments are often selected as \line \up0 \expndtw-9\chars
calex95 the amplication devices of choice when they present with hearing
\line \up0 \expndtw-10\charscalex95 impairment. \par\pard\qj \li1286\ri959\sb2\s
l-258\slmult0\fi478 \up0 \expndtw-10\charscalex95 The BTE-style hearing instrume
nt is more visible than other hear-\line \up0 \expndtw-9\charscalex94 ing aids w
orn at ear level but provides benets that smaller styles do not \line \up0 \expnd
tw-10\charscalex95 oer. For example, the biggest advantage to the BTE hearing aid
is the \line \up0 \expndtw-8\charscalex100 ability to use this hearing instrume
nt with telecoil capability and direct \line \up0 \expndtw-9\charscalex94 audio
input. The telecoil picks up electromagnetic signals, such as those \line \up0 \
expndtw-9\charscalex93 from telephones, and converts them into an electrical sig
nal that is ampli-\line \up0 \expndtw-9\charscalex98 ed by the hearing instru
ment. W|th direct audio input (DAI), the \line \up0 \expndtw-9\charscalex94
BTE hearing aid can be attached to a hardwire or wireless audio\ul0\nosupersub\
cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 boot,\ul0\nosupersub\cf
11\f12\fs22 \u8217?\u8217? \line \up0 \expndtw-8\charscalex100 \ul0\nosupersub\c
f2\f3\fs22 which links the hearing instrument to either a personal or sound eld \
line \up0 \expndtw-9\charscalex100 frequency-modulated (FM) amplication system.
The DAI allows the \line \up0 \expndtw-10\charscalex96 hearing aid microphone to
remain on while the FM signal is picked up. \line \up0 \expndtw-9\charscalex95
The DAI also can be connected to a television, stereo, tape recorder, or \line \
up0 \expndtw-9\charscalex91 personal radio. These components are addressed furth
er in the section on \line \up0 \expndtw-10\charscalex88 assistive technology. \
par\pard\ql \li1764\sb7\sl-253\slmult0\tx5605 \up0 \expndtw-10\charscalex96 The
ITE-style hearing instrument (Fig. 8.2) \tab \up0 \expndtw-10\charscalex96 ts in
the concha and \par\pard\qj \li1286\ri960\sb2\sl-260\slmult0 \up0 \expndtw-9\cha
rscalex97 outer ear cavity and is used to assist those with mild to severe heari
ng \line \up0 \expndtw-10\charscalex94 impairments. The ITE-style hearing instru
ment can provide more ampli-\line \up0 \expndtw-9\charscalex97 cation than canal
hearing aid styles, and individuals who do or do not \line \up0 \expndtw-9\chars
calex95 need glasses can use this style comfortably. In addition, those who pro\line \up0 \expndtw-7\charscalex100 duce little to moderate amounts of cerumen
(earwax) may nd this \line \up0 \expndtw-9\charscalex97 hearing aid style suitab
le for their needs. Because it is worn within the \line \up0 \expndtw-9\charscal
ex92 ear canal, it is more cosmetically appealing than larger hearing aid styles
, \line \up0 \expndtw-8\charscalex100 and individuals with good family support c
an still choose this model if \line \up0 \expndtw-10\charscalex94 their family h
elps them change the tiny battery. \par\pard\qj \li1286\ri961\sb0\sl-260\slmult0
\fi478 \up0 \expndtw-10\charscalex96 The ITC-style hearing instrument (Fig. 8.3)
is worn within the ear \line \up0 \expndtw-9\charscalex94 canal and can be used
for mild to moderate hearing loss. It is not able to \line \up0 \expndtw-10\cha
rscalex94 provide as much amplication as larger hearing aid styles. However,
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rd\li1551\sb137\sl-253\slmult0\fi0\tx2649 \up0 \expndtw-10\charscalex96 \ul0\nos
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fs18 Alternative Communication, Amplification, and Counseling\par\pard\li1551\sb
0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\s
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lmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par
\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li15
51\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult
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\li1551\sb160\sl-207\slmult0\fi0\tx2557 \up0 \expndtw-7\charscalex100 Figure 8.1
\tab \up0 \expndtw-7\charscalex100 A behind-the-ear^style hearing instrument. (R
eprinted with permission\par\pard\li1551\sb11\sl-207\slmult0\fi0 \up0 \expndtw-7
\charscalex100 from W|dex Hearing Aid Company, Inc.)\par\pard\sect\sectd\fs24\pa
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00a28a2800a28a2800a28a2800a28a2800a28a2800a28a2800a28a2803ffd9}}}}}\pard\sb0\sl240{\bkmkstart Pg197}{\bkmkend Pg197}\par\pard\li2996\sb0\sl-241\slmult0\par\par
d\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7208 \up0
\expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and Assistive
Technology\tab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 177\par
\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li12
86\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult
0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard
\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb
0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\s
lmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par
\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li12
86\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult
0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard
\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb65\sl-207\slmult0\fi0\tx2370 \up0 \
expndtw-7\charscalex100 \ul0\nosupersub\cf5\f6\fs18 Figure 8.2\tab \up0 \expndt

w-6\charscalex100 An in-the-ear^style hearing instrument. (Reprinted with p

ermission\par\pard\li1286\sb13\sl-207\slmult0\fi0 \up0 \expndtw-7\charscalex100
from W|dex Hearing Aid Compay, Inc.)\par\pard\sect\sectd\fs24\paperw8700\paperh1
3020{\shp
{\*\shpinst\shpleft0\shptop0\shpright8700\shpbottom13020\shpwr3\shpfblwtxt0\shpz
-10000\shplid197
{\sp{\sn shapeType}{\sv 75}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn pib}{\sv {\pict\jpegblip
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\sl-240{\bkmkstart Pg198}{\bkmkend Pg198}\par\pard\li1551\sb0\sl-253\slmult0\par
\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2652
\up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 178\tab \up0 \expndtw8\charscalex96 \ul0\nosupersub\cf5\f6\fs18 Alternative Communication, Amplificat
ion, and Counseling\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-20
7\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\
par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\l
i1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\
sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slm
ult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\p
ard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551

\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-20
7\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\
par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\l
i1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\
sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slm
ult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\p
ard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb161\sl-207\slmult0\fi0\tx2597 \u
p0 \expndtw-7\charscalex100 Figure 8.3\tab \up0 \expndtw-7\charscalex100 An inthe-canal^style hearing instrument. (Reprinted with permission\par\pard\li1551\s
b13\sl-207\slmult0\fi0 \up0 \expndtw-7\charscalex100 from Phonak Hearing Instrum
ents.)\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstar
t Pg199}{\bkmkend Pg199}\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\
sl-241\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7210 \up0 \expndtw-8\c
harscalex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\ta
b \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 179\par\pard\qj \li1
286\sb0\sl-240\slmult0 \par\pard\qj\li1286\ri961\sb78\sl-240\slmult0 \up0 \expnd
tw-9\charscalex96 individuals with poor manual dexterity or arthritis may experi
ence slight \line \up0 \expndtw-10\charscalex96 di\u8260?culty when manipulati
ng the user controls \up0 \expndtw-10\charscalex96 (e.g., battery door, \pa
r\pard\qj \li1286\ri959\sb4\sl-260\slmult0\tx1764 \up0 \expndtw-10\charscalex94
volume controls, and insertion and removal of the hearing instrument). \line\tab
\up0 \expndtw-10\charscalex96 Finally, the CIC-style hearing instrument (Fig. 8
.4) is worn deeply \line \up0 \expndtw-9\charscalex100 within the external ear c
anal and is used for mild to moderate hearing \line \up0 \expndtw-9\charscalex95
loss. Because the CIC-style hearing instrument is positioned completely \line \
up0 \expndtw-9\charscalex95 within the ear canal, it is cosmetically appealing a
nd often the amplica-\line \up0 \expndtw-5\charscalex100 tion style of choice for
many persons with hearing loss. Key to the \line \up0 \expndtw-9\charscalex97 s
uccessful use of this instrument is proper insertion and removal. A \line \
up0 \expndtw-7\charscalex100 built-in insertion and removal line that extends fr
om many CIC-style \line \up0 \expndtw-9\charscalex92 hearing instruments is prin
cipally how this task is accomplished (Fig. 8.5). \line \up0 \expndtw-8\charscal
ex100 Persons with disabilities who experience poor vision and dexterity or \lin
e \up0 \expndtw-9\charscalex100 arthritis may also encounter di\u8260?culty when
using the CIC-style hearing \line \up0 \expndtw-10\charscalex95 instrument. \pa
r\pard\ql \li3239\sb0\sl-207\slmult0 \par\pard\ql\li3239\sb0\sl-207\slmult0 \par
\pard\ql\li3239\sb150\sl-207\slmult0 \up0 \expndtw0\charscalex106 \ul0\nosupersu
b\cf7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17 EARING\ul0\nosupersub\cf7\f8\fs24
A\ul0\nosupersub\cf31\f32\fs17 ID\ul0\nosupersub\cf7\f8\fs24 C\ul0\nosupersub\c
f31\f32\fs17 IRCUITS \par\pard\qj \li1286\sb0\sl-258\slmult0 \par\pard\qj\li1286
\ri959\sb13\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex92 \ul0\nosupersub\c
f2\f3\fs22 Besides choosing a hearing aid style that best suits the person with
\line \up0 \expndtw-9\charscalex97 hearing impairment, there are also dierent typ
es of integrated circuitry \line \up0 \expndtw-10\charscalex96 that require cons
ideration: analog, digitally programmable analog, and \line \up0 \expndtw-8\char
scalex100 fully digital. It is important to note that any of these circuitry typ
es can \line \up0 \expndtw-7\charscalex100 be included within any hearing instru
ment style (i.e., BTE, ITE, ITC, \line \up0 \expndtw-9\charscalex93 and CIC), wh
ich greatly inuences the overall costs. Analog hearing aids \line \up0 \expndtw-9
\charscalex95 use conventional integrated circuitry for signal processing.
In other \line \up0 \expndtw-8\charscalex100 words, analog hearing instrument
s have a microphone that picks up \line \up0 \expndtw-9\charscalex100 continuou
sly varying sounds in the environment, converts the sounds \line \up0 \expndtw-9
\charscalex94 into an electrical signal, and amplies the electrical signal
, which is \line \up0 \expndtw-10\charscalex96 transduced via the receiver bac
k to acoustic sounds to t the needs of \line \up0 \expndtw-9\charscalex92 the hea
ring aid user. This hearing aid circuit is considered linear, because \line \up0
\expndtw-9\charscalex95 it amplies all sounds to the capable limits of the devic
e, no matter how \line \up0 \expndtw-9\charscalex100 loud the incoming sounds
are. Most analog hearing instruments are \line \up0 \expndtw-9\charscalex100 sui

table for patients who need basic amplication at the lowest price. \line \up0 \ex
pndtw-6\charscalex100 Patients who have di\u8260?culty adjusting to new technolo
gy and who do \line \up0 \expndtw-10\charscalex95 not spend time in various envi
ronments with many people may nd this \line \up0 \expndtw-10\charscalex96 type of
circuitry adequate. \par\pard\qj \li1286\ri959\sb1\sl-260\slmult0\fi478 \up0 \e
xpndtw-8\charscalex100 Digitally programmable analog (hybrid) circuitry function
s in the \line \up0 \expndtw-10\charscalex95 same fashion as analog circuitry; h
owever, the parameters in which the
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b \up0 \expndtw-8\charscalex97 \ul0\nosupersub\cf5\f6\fs18 Alternative Communica
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li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li
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\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\s
b0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0
\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\s
l-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-22
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\sl-220\slmult0\tx2620 \up0 \expndtw-7\charscalex100 Figure 8.4 \tab \up0 \expn
dtw-6\charscalex100 A completely-in-the-canel^style hearing instrument. (Repri
nted with \line\up0 \expndtw-8\charscalex97 permission from W|dex Hearing Aid Co
mpany, Inc.) \par\pard\sect\sectd\fs24\paperw8700\paperh13020{\shp
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50014514500145145007ffd9}}}}}\pard\sb0\sl-240{\bkmkstart Pg201}{\bkmkend Pg201}\
par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\sl-241\slmult0\par\pard\l
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tration of an insertion and removal line on a completely-in-the-\par\pard\li1286
\sb13\sl-207\slmult0\fi0 \up0 \expndtw-5\charscalex100 canal^style hearing instr
ument.\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstar
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charscalex97 \ul0\nosupersub\cf2\f3\fs22 182\tab \up0 \expndtw-8\charscalex97 \u
l0\nosupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseli
ng\par\pard\qj \li1551\sb0\sl-262\slmult0 \par\pard\qj\li1551\ri694\sb66\sl-262\
slmult0 \up0 \expndtw-9\charscalex95 \ul0\nosupersub\cf2\f3\fs22 signals are pro
cessed are controlled digitally. That is, the integrated cir-\line \up0 \expndtw
-9\charscalex95 cuitry makes use of a cable connection from the hearing instrume
nt to a \line \up0 \expndtw-10\charscalex93 personal computer or special program
ming equipment, which allows the \line \up0 \expndtw-9\charscalex94 hearing heal
th care practitioner to determine the boundaries in which the \line \up0 \expndt
w-9\charscalex92 hearing aid amplies sounds. The analog parameters can be
altered \line \up0 \expndtw-10\charscalex97 and sound quality comparisons can b
e determined in terms of speech \line \up0 \expndtw-9\charscalex95 understanding
and noise as well as in quiet conditions. Instead of linear \line \up0 \expndtw
-9\charscalex94 amplication, digitally programmable analog circuitry uses compres
sion, \line \up0 \expndtw-9\charscalex100 a means of providing amplication by boo
sting soft sounds to audible \line \up0 \expndtw-10\charscalex94 levels and supp
ressing loud sounds to levels that are more comfortable \line \up0 \expndtw-10\c
harscalex91 and compatible with the person\ul0\nosupersub\cf11\f12\fs22 \u8217?\

ul0\nosupersub\cf2\f3\fs22 s hearing loss. \par\pard\qj \li1551\ri694\sb0\sl-261

\slmult0\fi478 \up0 \expndtw-10\charscalex95 Fully digital hearing instruments a
re the most advanced and most \line \up0 \expndtw-10\charscalex95 expensive type
s of integrated circuitry. Incoming sounds are converted \line \up0 \expndtw-10\
charscalex93 into binary numbers, which are then analyzed and manipulated via a
set \line \up0 \expndtw-9\charscalex100 of rules (algorithms) programmed into th
e computer chip that controls \line \up0 \expndtw-9\charscalex94 the hearing ins
trument. Fully digital circuitry also makes use of compres-\line \up0 \expndtw-1
0\charscalex96 sion and a cable connection from the hearing instrument to a pers
onal \line \up0 \expndtw-10\charscalex95 computer or special programming equipme
nt, which allows the hearing \line \up0 \expndtw-9\charscalex97 health care prac
titioner to manipulate the settings. Thus digital hearing \line \up0 \expndtw-9\
charscalex94 aid circuitry has much more exibility for processing sounds (e.g., u
se of \line \up0 \expndtw-10\charscalex96 preprogrammed settings that can be use
d when a person moves from \line \up0 \expndtw-9\charscalex95 quiet environment
s to noisy environments) than analog and strictly \line \up0 \expndtw-5\c
harscalex100 bound hybrid integrated circuits. Patients who do not have di\u8260
?culty \line \up0 \expndtw-8\charscalex100 adjusting to new technology and who s
pend time in various environ-\line \up0 \expndtw-10\charscalex97 ments will nd th
is type of circuitry appropriate. \par\pard\ql \li2578\sb0\sl-280\slmult0 \par\p
ard\ql\li2578\ri1817\sb103\sl-280\slmult0\tx3518 \up0 \expndtw0\charscalex105 \u
l0\nosupersub\cf7\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 ELECTION\ul0\nosupersub
\cf7\f8\fs24 , F\ul0\nosupersub\cf31\f32\fs17 ITTING\ul0\nosupersub\cf7\f8\fs24
,\ul0\nosupersub\cf31\f32\fs17 AND\ul0\nosupersub\cf7\f8\fs24 V\ul0\nosupersub
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rsub\cf7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17 EARING\ul0\nosupersub\cf7\f8\fs2
4 I\ul0\nosupersub\cf31\f32\fs17 NSTRUMENTS \par\pard\qj \li1551\ri696\sb254\sl
-264\slmult0\fi478 \up0 \expndtw-10\charscalex97 \ul0\nosupersub\cf2\f3\fs22 Sel
ection and tting of hearing instruments often starts by deter-\line \up0 \expndtw
-9\charscalex100 mining whether the person is a candidate for amplication. Denitiv
e \line \up0 \expndtw-10\charscalex96 candidacy requirements can vary from one h
earing health care profes-\line \up0 \expndtw-10\charscalex95 sional to another,
yet most individuals are considered candidates when \line \up0 \expndtw-9\chars
calex96 their hearing impairment aects the audiometric frequency range that is \l
ine \up0 \expndtw-10\charscalex96 critical for clear understanding of speech \
up0 \expndtw-10\charscalex88 (i.e., \up0 \expndtw-10\charscalex96 1^ 4 kHz). In
pediatric \par\pard\qj \li1551\ri696\sb0\sl-260\slmult0 \up0 \expndtw-9\charsca
lex93 patients or in patients with unreliable behavioral responses during routin
e \line \up0 \expndtw-10\charscalex93 audiometric tests, candidacy can be determ
ined via auditory brainstem
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
203}{\bkmkend Pg203}\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\sl-2
41\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7206 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \u
p0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 183\par\pard\qj \li1286\
sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw-9
\charscalex97 response tests (Dalzell et al., 2000; Lin, Shu, Chang, & Bruna,
2002; \line \up0 \expndtw-10\charscalex91 Mason & Herrmann, 1998; Sakai,Watanab
e, & Kaga, 2002). The decision \line \up0 \expndtw-9\charscalex91 for hearing in

strument use can be based on these audiometric data as well \line \up0 \expndtw10\charscalex91 as on equally important nonaudiometric components such as age, s
peech \line \up0 \expndtw-9\charscalex93 and language development, existence of
other medical conditions, family \line \up0 \expndtw-10\charscalex97 and ancilla
ry support, motivation level, or special needs. From a more \line \up0 \expndtw9\charscalex94 subjective point of view, candidacy for hearing aid use is highly
probable \line \up0 \expndtw-9\charscalex96 when the person with hearing di\u82
60?culty reports that others are constantly \line \up0 \expndtw-6\charscalex100
mumbling during conversations, has the ability to hear and not fully \line \up0
\expndtw-9\charscalex93 understand what others are saying, has a longstanding hi
story of hearing \line \up0 \expndtw-7\charscalex100 di\u8260?culty across vario
us environments, or is constantly turning up the \line \up0 \expndtw-5\charscale
x100 volume on the television or radio to the point at which other family \line
\up0 \expndtw-10\charscalex93 members complain. Each of these nonaudiometri
c components can \line \up0 \expndtw-7\charscalex100 greatly inuence hearing in
strument use or the amount of additional \line \up0 \expndtw-10\charscalex96 hab
ilitation or rehabilitation involved. \par\pard\qj \li1286\ri961\sb1\sl-260\slmu
lt0\fi478 \up0 \expndtw-10\charscalex92 Once a person has undergone an audiometr
ic evaluation, it is often \line \up0 \expndtw-10\charscalex95 recommended that
the person obtain medical clearance for hearing aid \line \up0 \expndtw-6\charsc
alex100 use. Guidelines set forth by the U.S. Food and Drug Administration \line
\up0 \expndtw-9\charscalex94 indicate that all children require written medical
clearance by a physician \line \up0 \expndtw-10\charscalex94 and/otorhinolaryng
ologist \up0 \expndtw-10\charscalex94 (ear-nose-and-throat specialist) for he
aring \par\pard\qj \li1286\ri959\sb2\sl-258\slmult0\fi0 \up0 \expndtw-10\charsca
lex95 instrument use, and this clearance should be obtained within 6 months \lin
e \up0 \expndtw-9\charscalex95 prior to the date of sale of the hearing
instrument or instruments. \line \up0 \expndtw-9\charscalex92 However, indivi
duals 18 years of age and older may either obtain medical \line \up0 \expndtw-9\
charscalex95 clearance or sign a waiver in lieu of obtaining medical clearance.
When \line \up0 \expndtw-9\charscalex92 this occurs and the person has been dete
rmined as a candidate for ampli-\line \up0 \expndtw-9\charscalex92 cation, the he
aring instrument tting process ensues. In this process, the \line \up0 \expndtw-9
\charscalex96 hearing health care professional will work with the client to sele
ct hear-\line \up0 \expndtw-9\charscalex97 ing instrument style and integrated c
ircuitry, gain, frequency response, \line \up0 \expndtw-10\charscalex95 and maxi
mum power output characteristics. The term gain refers to the \line \up0 \expndt
w-9\charscalex95 dierence in loudness (measured in decibel sound pressure lev
el [dB \line \up0 \expndtw-7\charscalex100 SPL]) between the sound going into t
he hearing instrument and the \line \up0 \expndtw-10\charscalex96 sound leaving
the hearing instrument. For instance, if the sound going \line \up0 \expndtw-8\c
harscalex100 into the hearing instrument is 45 dB SPL and the sound leaving th
e \line \up0 \expndtw-8\charscalex100 hearing instrument is 75 dB SPL, then the
hearing instrument in this \line \up0 \expndtw-9\charscalex95 case has 30 dB of
gain. When gain is plotted as a function of frequency \line \up0 \expndtw-9\char
scalex93 (measured in Hz), it creates a distribution across dierent sounds that a
re \line \up0 \expndtw-9\charscalex100 amplied by the device, otherwise known as
the frequency response \line \up0 \expndtw-10\charscalex96 (Lucks-Mendel, Danhau
er, & Singh, 1999). Finally, maximum power
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz95\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}

}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
204}{\bkmkend Pg204}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2660 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 184\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\qj \li1551\sb0\sl-250\slmult0 \par\pard\qj\li1551\ri695\sb88\sl-250\slmu
lt0 \up0 \expndtw-9\charscalex95 \ul0\nosupersub\cf2\f3\fs22 output refers to a
level beyond that which the hearing instrument cannot \up0 \expndtw-9\charscalex
94 amplify and serves as a means of protecting the hearing instrument user \up0
\expndtw-10\charscalex94 from uncomfortably loud sounds. \par\pard\qj \li1551\ri
694\sb2\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex92 The hearing instrumen
t selection process usually occurs before the \line \up0 \expndtw-9\charscalex91
actual hearing aid tting session itself; hence, focus is placed on preselect-\li
ne \up0 \expndtw-9\charscalex100 ing the necessary gain and maximum power output
values. Gain and \line \up0 \expndtw-10\charscalex93 maximum power output value
s rely heavily on computer-based prescrip-\line \up0 \expndtw-9\charscalex95 tiv
e hearing instrument tting formulas a blueprint that links a person\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s \line \up0 \expndtw-9\cha
rscalex95 hearing-impairment to certain amplication characteristics. Examples of
\line \up0 \expndtw-10\charscalex95 common prescription-based hearing instrum
ent \up0 \expndtw-10\charscalex95 tting formulas are \par\pard\qj \li1551\ri696
\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex95 shown in Table 8.1. These pres
cription-based tting formulas are often \up0 \expndtw-9\charscalex93 selected ac
cording to audiometric hearing thresholds, suprathreshold \up0 \expndtw-7\c
harscalex100 perception of loudness, and listening situations in which the heari
ng \up0 \expndtw-10\charscalex96 instruments will be worn. For extended reviews
of prescriptive hearing \up0 \expndtw-7\charscalex100 instrument tting formulas,
the interested reader is directed to Dillon \up0 \expndtw-10\charscalex87 (2001)
and Valente (2002a, 2002b). \par\pard\qj \li1551\ri694\sb1\sl-259\slmult0\fi478
\up0 \expndtw-7\charscalex100 To document the adequacy of the hearing instrumen
t after the \line \up0 \expndtw-9\charscalex94 tting process has occurred, it is
essential to verify the hearing aid tting \line \up0 \expndtw-10\charscalex92 usi
ng both objective and subjective measures. Perhaps the most popular \line \up0 \
expndtw-10\charscalex95 objective means of hearing aid verication is real ear mea
surements \line \up0 \expndtw-8\charscalex100 determining the functional propert
ies of the hearing instrument while \line \up0 \expndtw-9\charscalex94 the user
is wearing the hearing instrument. Advances in measuring \line \up0 \ex
pndtw-10\charscalex95 hearing aid performance in this manner have led to the dev
elopment of \line \up0 \expndtw-9\charscalex100 commercially available equipment
and probe tube microphone instru-\line \up0 \expndtw-10\charscalex96 mentation
(Mueller, Hawkins, & Northern, 1992). This allows measure-\line \up0 \expndtw-9\
charscalex97 ment of the response of the hearing instrument while it i
s in the \line \up0 \expndtw-9\charscalex96 person\ul0\nosupersub\cf11\f12\fs2
2 \u8217?\ul0\nosupersub\cf2\f3\fs22 s ear at quiet, mid, and high intensity lev
els. Conversely, a sub-\line \up0 \expndtw-9\charscalex95 jective method used to
verify hearing instrument performance is obtain-\line \up0 \expndtw-10\charscal
ex96 ing behavioral functional gain, which involves measuring the dierence \line
\up0 \expndtw-9\charscalex95 between speech perception ability with (aided) vers
us without (unaided) \line \up0 \expndtw-9\charscalex94 hearing instruments. As
an alternative to behavioral functional gain mea-\line \up0 \expndtw-9\charscale
x96 sures, an equally important subjective process used to verify hearing \li
ne \up0 \expndtw-7\charscalex100 instrument performance is obtaining a self-repo
rt of benet from the \line \up0 \expndtw-10\charscalex95 hearing aid user. These
hearing aid benet measures serve to quantify \line \up0 \expndtw-9\charscalex98 h
ow hearing aid use aects the fulllment of life activities with specic \line \up0 \e
xpndtw-10\charscalex96 emphasis on daily communication (McCarthy, 1997). Among t
he more \line \up0 \expndtw-9\charscalex91 common self-assessment scales used
to measure hearing aid benet \line \up0 \expndtw-10\charscalex91 and how he
aring impairment aects the social and emotional aspects of

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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz96\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
205}{\bkmkend Pg205}\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\sl-2
41\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7203 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \u
p0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 185\par\pard\ql \li4059\
sb0\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb
0\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb0\
sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl
-207\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-2
07\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-207
\slmult0 \par\pard\ql\li4059\sb0\sl-207\slmult0 \par\pard\ql\li4059\sb0\sl-207\s
lmult0 \par\pard\ql\li4059\sb115\sl-207\slmult0 \up0 \expndtw-8\charscalex94 \ul
0\nosupersub\cf5\f6\fs18 Table 8.1 \par\pard\ql \li1640\sb73\sl-207\slmult0 \up0
\expndtw-1\charscalex100 Examples of Prescription-Based Hearing Instrument Fitt
ing Formulas \par\pard\ql \li1286\sb173\sl-207\slmult0\tx2510 \up0 \expndtw-4\ch
arscalex100 DSL [i/o] \tab \up0 \expndtw-8\charscalex96 Desired Sensation Level
Input-Output for Compression Amplification \par\pard\ql \li2510\sb13\sl-207\slmu
lt0 \up0 \expndtw-8\charscalex88 (Cornelisse, Seewald, & Jamieson, 1955) \par\pa
rd\li1286\sb24\sl-207\slmult0\fi0\tx2510 \up0 \expndtw-8\charscalex94 FIG6\tab \
up0 \expndtw-8\charscalex94 Figure 6 Fitting Procedure\par\pard\ql \li2510\sb2\s
l-207\slmult0 \up0 \expndtw-8\charscalex93 (Killion & Fikret-Pasa, 1993) \par\pa
rd\li1286\sb22\sl-207\slmult0\fi0\tx2510 \up0 \expndtw-8\charscalex95 IHAFF\tab
\up0 \expndtw-8\charscalex95 Indenpendent Hearing Aid Fitting Forum Loudness Sca
ling Procedure\par\pard\ql \li2510\sb4\sl-207\slmult0 \up0 \expndtw-8\charscalex
92 (Cox, 1995;Valente & VanVliet, 1997) \par\pard\li1286\sb21\sl-207\slmult0\fi0
\tx2510 \up0 \expndtw-8\charscalex96 LGOB\tab \up0 \expndtw-8\charscalex96 Loudn
ess Growth in Half-Octave Bands\par\pard\ql \li2510\sb5\sl-207\slmult0 \up0 \exp
ndtw-8\charscalex92 (Allen, Hall, & Jeng, 1990) \par\pard\li1286\sb20\sl-207\slm
ult0\fi0\tx2510 \up0 \expndtw-8\charscalex96 NAL\tab \up0 \expndtw-8\charscalex9
6 National Acoustic Laboratories Fitting Procedure\par\pard\ql \li2510\sb6\sl-20
7\slmult0 \up0 \expndtw-8\charscalex90 Byrne & Tonisson, 1976) \par\pard\ql \li1
286\sb13\sl-207\slmult0\tx2510 \up0 \expndtw0\charscalex100 NAL-NL1 \tab \up0 \e
xpndtw-8\charscalex94 National Acoustic Laboratories, Nonlinear,Version 1 \par\p
ard\ql \li2510\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex95 (Dillon, 1999) \
par\pard\li1286\sb16\sl-207\slmult0\fi0\tx2510 \up0 \expndtw-7\charscalex100 POG
O\tab \up0 \expndtw-7\charscalex100 Prescription of Gain and Output\par\pard\ql
\li2510\sb10\sl-207\slmult0 \up0 \expndtw-8\charscalex89 (McCandless & Lyregaard
, 1983)
{\shp {\*\shpinst\shpleft1286\shptop4528\shpright7503\shpbottom4549\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz6\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 21}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(6217,0);(6217,21);(0,21)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp {\*\shpinst\shpleft1286\shptop7804\shpright7503\shpbottom7824\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(6217,0);(6217,20);(0,20)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz48\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
206}{\bkmkend Pg206}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2659 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 186\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\ql \li1551\sb0\sl-258\slmult0 \par\pard\ql\li1551\ri694\sb73\sl-258\slmu
lt0\tx2030\tx2030 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 hear
ing loss are the Abbreviated Prole of Hearing Aid Benet \line \up0 \expnd
tw-9\charscalex100 (APHAB) and the Hearing Handicap Inventory for the Elderly (H
HIE). \line\tab \up0 \expndtw-10\charscalex95 The APHAB, which is a condensed ve
rsion of the 64 -item Prole \line \up0 \expndtw-10\charscalex95 of Hearing Aid Be
net (PHAB) (Cox & Rivera, 1992), is a standardized \line \up0 \expndtw-9\charscal
ex89 24 -item self-assessment tool designed to assess auditory performance with
\line \up0 \expndtw-10\charscalex96 and without hearing aids across various list
ening environments (Cox & \line \up0 \expndtw-9\charscalex89 Alexander, 1995). T
he 24 questions are divided into four subscales (Ease of \line \up0 \expndtw-10\
charscalex95 Communication [EC], Background Noise [BN], Reverberation [RV], and
\line \up0 \expndtw-9\charscalex91 Aversiveness of Sounds [AV]), consisting of s
ix questions each. Individuals \line \up0 \expndtw-9\charscalex95 are instructed
to answer according to a seven-point response scale with \line \up0 \expndtw-9\
charscalex92 assigned percentages (i.e., always, 99%; almost always, 87%; gener
ally, \line \up0 \expndtw-10\charscalex93 75%; half the time, 50%; occasionally,
25%; seldom, 12%; never, 1%) to \line \up0 \expndtw-8\charscalex100 each compon
ent. All items on the APHAB are answered twice, once \line \up0 \expndtw-10\char
scalex94 for\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\
fs22 without the hearing aid\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nos
upersub\cf2\f3\fs22 and again for\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\u
l0\nosupersub\cf2\f3\fs22 with the hearing aid.\ul0\nosupersub\cf11\f12\fs22 \u8
217?\u8217? \line \tab \up0 \expndtw-10\charscalex92 \ul0\nosupersub\cf2\f3\fs22
The HHIE (Ventry & Weinstein, 1982) is a 25 -question self-assess-\line \up0 \e
xpndtw-9\charscalex100 ment tool designed to assess the eects of hearing impairme
nt on the \line \up0 \expndtw-9\charscalex93 emotional and social adjustment of
adults older than age 65 years. There \line \up0 \expndtw-8\charscalex100 is als
o a version of this inventory that can be used for adults younger \line \up0 \ex
pndtw-9\charscalex100 than age 65 years, the Hearing Handicap Inventory for Adul
ts (HHIA) \line \up0 \expndtw-10\charscalex96 (Newman, Weinstein, Jacobson, &
Hug, 1990). The HHIE/A has a \line \up0 \expndtw-10\charscalex94 13 -item s

ubscale that explores the emotional consequences of hearing \line \up0 \expndtw10\charscalex95 impairment and a 12-item subscale that explores both social and
situa-\line \up0 \expndtw-9\charscalex95 tional eects of hearing impairment. Indi
viduals are instructed to answer \line \up0 \expndtw-9\charscalex92 \ul0\nosuper
sub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 Yes,\ul0\nosupersub\
cf11\f12\fs22 \u8217?\u8217? \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 Sometimes
,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 or\ul0
\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 No\ul0\nosu
persub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 for each item. R
esponses are allocated 4, 2, \line \up0 \expndtw-9\charscalex93 and 0 points, re
spectively, and scores for each subscale are combined to \line \up0 \expndtw-10\
charscalex93 produce a total score. The minimum possible score that can be obtai
ned \line \up0 \expndtw-10\charscalex97 on the HHIE/A is 0, whereas the maximum
possible score that can be \line \up0 \expndtw-10\charscalex96 obtained on the H
HIE/A is 100. Higher scores indicate increased emo-\line \up0 \expndtw-9\charsca
lex100 tional, social, and situational di\u8260?culties associated with hearing
impair-\line \up0 \expndtw-8\charscalex100 ment. W|th the APHAB and the HHIE/A,
verication of the amount of \line \up0 \expndtw-9\charscalex92 hearing aid benet i
s demonstrated by the dierence in scores before and \line \up0 \expndtw-10\charsc
alex92 after hearing aid tting (Humes, Halling, & Coughlin, 1996). \par\pard\ql \
li2554\sb0\sl-207\slmult0 \par\pard\ql\li2554\sb0\sl-207\slmult0 \par\pard\ql\li
2554\sb151\sl-207\slmult0 \up0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs
24 T\ul0\nosupersub\cf31\f32\fs17 ROUBLESHOOTING\ul0\nosupersub\cf7\f8\fs24 H\u
l0\nosupersub\cf31\f32\fs17 EARING\ul0\nosupersub\cf7\f8\fs24 I\ul0\nosupersub\
cf31\f32\fs17 NSTRUMENTS \par\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li
1551\ri695\sb10\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupers
ub\cf2\f3\fs22 Over the course of hearing instrument use, various circumstances
\line \up0 \expndtw-9\charscalex95 under which the hearing aid will malfunction
and require routine checks
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz91\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
207}{\bkmkend Pg207}\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\sl-2
41\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7201 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \u
p0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 187\par\pard\qj \li1286\
sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0 \up0 \expndtw-8
\charscalex100 will be seen. The most straightforward way to determine whether t
he \line \up0 \expndtw-9\charscalex97 hearing instrument has malfunctioned i
s to use a troubleshooting \line \up0 \expndtw-9\charscalex100 sequence or a
series of steps to follow that allows hearing instrument \line \up0 \expndtw-9\
charscalex96 users to ascertain why their hearing instrument is not working prop
erly. \line \up0 \expndtw-7\charscalex100 The initial step to determine a faulty
hearing instrument is a general \line \up0 \expndtw-9\charscalex98 cleaning of
the device. During this process a soft cloth can be used to \line \up0 \expndtw10\charscalex97 remove dirt, moisture, or cerumen from all surface areas. Clogs
in the \line \up0 \expndtw-9\charscalex95 earmold should be cleaned using t
he earmold tubing blower. After \line \up0 \expndtw-9\charscalex100 the gene
ral cleaning, another step is for the user to physically inspect \line \up0 \exp
ndtw-10\charscalex95 the hearing instrument to determine whether the casing has
any cracks \line \up0 \expndtw-9\charscalex100 or broken parts. For instance, cr

acks in the BTE hearing aid tubing or \line \up0 \expndtw-10\charscalex97 cracks
and broken parts in the shell casing may require an immediate \line \up0 \expnd
tw-10\charscalex93 visit to the hearing health care professional for repair. \pa
r\pard\qj \li1286\ri960\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 A
next step in the troubleshooting process is determining that the \line \up0 \ex
pndtw-6\charscalex100 battery is properly placed within the hearing instrument.
As with all \line \up0 \expndtw-9\charscalex92 batteries, these have both a posi
tive and a negative side, and their correct \line \up0 \expndtw-9\charscalex93 p
lacement within the hearing instrument is usually determined by either a \line \
up0 \expndtw-10\charscalex93 plus () or minus ( \up0 \expndtw-10\charscalex93 ) s
ign shown on the battery door. This circumstance \par\pard\qj \li1286\ri962\sb0\
sl-260\slmult0 \up0 \expndtw-10\charscalex90 serves as both an advantage and a d
isadvantage, because only with good \line \up0 \expndtw-10\charscalex91 vision o
r under adequate magnication can this\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216
?\ul0\nosupersub\cf2\f3\fs22 \ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nos
upersub\cf2\f3\fs22 or\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216? \up0 \expnd
tw-10\charscalex87 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 sign be seen. \par
\pard\qj \li1286\ri959\sb5\sl-255\slmult0 \up0 \expndtw-9\charscalex95 To ease s
ome of the di\u8260?culties that arise with correct battery placement, \line \up
0 \expndtw-9\charscalex95 battery dispensers are available. A battery dispenser
is a relatively new \line \up0 \expndtw-9\charscalex100 device that simplies the
process by allowing the user to transfer the \line \up0 \expndtw-7\charscalex100
battery directly from the packaging into the hearing instrument. This \line \up
0 \expndtw-9\charscalex90 reduces the chances of dropping and losing the battery
during the process. \par\pard\qj \li1286\ri959\sb1\sl-260\slmult0\fi478 \up0 \e
xpndtw-10\charscalex93 Two other items equally important to correct battery plac
ement are \line \up0 \expndtw-9\charscalex95 making sure that the battery co
ntacts inside the hearing instrument \line \up0 \expndtw-9\charscalex93 are
clean and free of corrosive materials and that the correct size battery \line \u
p0 \expndtw-9\charscalex97 is being used. Table 8.2 provides information on batt
ery sizes for each \line \up0 \expndtw-9\charscalex94 hearing instrument style (
i.e., BTE, ITE, ITC, and CIC); these sizes have \line \up0 \expndtw-10\charscale
x95 color-coded tabs for easy identication when they are purchased. Most \line \u
p0 \expndtw-9\charscalex94 hearing aid batteries are known as Zinc-Air, or are c
onstructed to use air \line \up0 \expndtw-9\charscalex94 from outside the batter
y as the activating agent once the color-coded tab \line \up0 \expndtw-9\charsca
lex94 is removed. Although most Zinc-Air batteries produce 1.3 to 1.5
V, \line \up0 \expndtw-6\charscalex100 replacing the color-coded tab when the ba
ttery is not in use will not \line \up0 \expndtw-7\charscalex100 extend the batt
ery life. Battery life uctuates according to conditions \line \up0 \expndtw-10\c
harscalex96 such as the number of hours each day the hearing instrument is being
\line \up0 \expndtw-9\charscalex95 used, the volume control settings while the
hearing instrument is in use,
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
208}{\bkmkend Pg208}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2660 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 188\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li

1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\s
l-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmu
lt0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pa
rd\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\
sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207
\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\p
ar\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li
1551\sb195\sl-207\slmult0\fi2768 \up0 \expndtw-6\charscalex100 Table 8.2\par\par
d\li1551\sb71\sl-207\slmult0\fi865 \up0 \expndtw-6\charscalex100 Available ZincAir Battery Sizes for Hearing Instruments\par\pard\li1551\sb176\sl-207\slmult0\f
i0\tx3615\tx6631 \up0 \expndtw-6\charscalex100 Battery size\tab \up0 \expndtw-6\
charscalex100 Hearing instrument style\tab \up0 \expndtw-6\charscalex100 Color c
oded tab\par\pard\li1551\sb11\sl-207\slmult0\fi0\tx3615\tx6631 \up0 \expndtw-6\c
harscalex100 675\tab \up0 \expndtw-6\charscalex100 BTE\tab \up0 \expndtw-6\chars
calex100 Blue\par\pard\li1551\sb13\sl-207\slmult0\fi0\tx3615\tx6631 \up0 \expndt
w-6\charscalex100 13\tab \up0 \expndtw-6\charscalex100 BTE or ITE\tab \up0 \expn
dtw-6\charscalex100 Orange\par\pard\li1551\sb12\sl-207\slmult0\fi0\tx3615\tx6631
\up0 \expndtw-6\charscalex100 312\tab \up0 \expndtw-6\charscalex100 ITE or ITC\
tab \up0 \expndtw-6\charscalex100 Brown\par\pard\li1551\sb12\sl-207\slmult0\fi0\
tx1741\tx3615\tx6631 \up0 \expndtw-8\charscalex76 10\tab \up0 \expndtw-6\charsca
lex100 (10A)\tab \up0 \expndtw-6\charscalex100 ITC or CIC\tab \up0 \expndtw-6\ch
arscalex100 Yellow\par\pard\li1551\sb13\sl-207\slmult0\fi0\tx1675\tx3615\tx6631
\up0 \expndtw-6\charscalex100 5\tab \up0 \expndtw-6\charscalex100 (5A)\tab \up0
\expndtw-6\charscalex100 CIC\tab \up0 \expndtw-6\charscalex100 Red
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 21}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(6217,0);(6217,21);(0,21)}}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1551\shptop7127\shpright7768\shpbottom7147\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz34\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg

209}{\bkmkend Pg209}\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\sl-2
41\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7199 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \u
p0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 189\par\pard\qj \li1286\
sb0\sl-240\slmult0 \par\pard\qj\li1286\ri959\sb78\sl-240\slmult0 \up0 \expndtw-6
\charscalex100 the size of the battery, and the type of integrated circuitry wit
hin the \up0 \expndtw-10\charscalex95 hearing instrument. \par\pard\qj \li1286\r
i959\sb4\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex92 Once the hearing ins
trument has been cleaned, is determined to be \line \up0 \expndtw-10\charscalex9
2 free from any cracks and breaks, and has an adequately charged battery \line \
up0 \expndtw-7\charscalex100 that is properly inserted, the nal step is a listen
ing check. A person \line \up0 \expndtw-7\charscalex100 who does not have any he
aring di\u8260?culty should perform the listening \line \up0 \expndtw-9\charscal
ex92 check, and a hearing aid stethoscope (Fig. 8.6) should be used to conduct \
line \up0 \expndtw-9\charscalex96 this component of the troubleshooting pro
cess. By turning on and \line \up0 \expndtw-8\charscalex100 attaching the he
aring instrument to the hearing aid stethoscope, the \line \up0 \expndtw-9\char
scalex96 listener can determine the clarity of sounds such as /u/ /i/, /s/, /sh/
, /m/, \line \up0 \expndtw-10\charscalex94 and /n/. While adjustments are made t
o the volume, an inventory of any \line \up0 \expndtw-9\charscalex94 intermitten
ce, static, unexplained feedback, or interference is also made \line \up0 \expnd
tw-9\charscalex93 while the person talks at various loudness levels. Unw
anted sounds \line \up0 \expndtw-10\charscalex94 (e.g., humming or static) dete
rmined during the process would probably \line \up0 \expndtw-9\charscalex93 requ
ire further troubleshooting or repair. In addition to these suggestions, \line \
up0 \expndtw-8\charscalex100 a regularly scheduled maintenance plan with the hea
ring health care \line \up0 \expndtw-9\charscalex95 professional should allow fo
r more exhaustive evaluation and resolution \line \up0 \expndtw-10\charscalex95
of any hearing aid malfunction. \par\pard\ql \li1685\sb0\sl-207\slmult0 \par\par
d\ql\li1685\sb0\sl-207\slmult0 \par\pard\ql\li1685\sb150\sl-207\slmult0 \up0 \ex
pndtw0\charscalex103 \ul0\nosupersub\cf7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17
EARING\ul0\nosupersub\cf7\f8\fs24 I\ul0\nosupersub\cf31\f32\fs17 NSTRUMENTS VER
SUS\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 SSISTIVE\ul0\nosu
persub\cf7\f8\fs24 T\ul0\nosupersub\cf31\f32\fs17 ECHNOLOGY \par\pard\qj \li128
6\sb0\sl-257\slmult0 \par\pard\qj\li1286\ri959\sb15\sl-257\slmult0\fi478 \up0 \e
xpndtw-6\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Amplication in the form of hea
ring instruments is considered \line \up0 \expndtw-9\charscalex97 the primary o
ption for many individuals who are hearing-impaired; \line \up0 \expndtw-9
\charscalex95 however, they are not designed to address every listener\u
l0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s needs. \line \
up0 \expndtw-10\charscalex96 The rapid development of hearing instrument technol
ogy over the past \line \up0 \expndtw-9\charscalex93 several years has made it p
ossible to produce higher delity instruments, \line \up0 \expndtw-9\charscalex96
yet the biggest limitation often reported among hearing aid users is the \line \
up0 \expndtw-10\charscalex95 inability to clearly comprehend the spoken message
in the presence of \line \up0 \expndtw-7\charscalex100 competing noise or when t
he listener is not in close proximity to the \line \up0 \expndtw-10\charscalex89
person speaking (Flexer, 1999; Franks & Beckmann, 1985). \par\pard\qj \li1286\r
i959\sb1\sl-260\slmult0\fi478 \up0 \expndtw-9\charscalex100 Despite miniaturizat
ion of hearing instruments (the trend toward \line \up0 \expndtw-9\charscalex93
increasingly smaller hearing instruments), large numbers of persons with \line \
up0 \expndtw-6\charscalex100 hearing impairment choose not to use them. An exami
nation of the \line \up0 \expndtw-9\charscalex95 literature concerning the reaso
ns for this discrepancy between the num-\line \up0 \expndtw-8\charscalex100 bers
of individuals in the United States with hearing loss who require \line \up0 \e
xpndtw-9\charscalex94 hearing aid use and those who actually use hearing aids re
veals several \line \up0 \expndtw-9\charscalex94 factors. These factors inclu
de social stigma, instrument reliability,
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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020{\shp
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{\sp{\sn pib}{\sv {\pict\jpegblip
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28a28a0028a28a0028a28a0028a28a0028a28a0028a28a0028a28a00ffd9}}}}}\pard\sb0\sl-24
0{\bkmkstart Pg210}{\bkmkend Pg210}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\
li1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2658 \up0 \
expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 190\tab \up0 \expndtw-8\char
scalex95 \ul0\nosupersub\cf5\f6\fs18 Alternative Communication, Amplification, a
nd Counseling\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmu
lt0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pa
rd\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\
sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207
\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\p
ar\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li
1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\s
l-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmu
lt0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pa
rd\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\
sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207
\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\p
ar\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li
1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\s
l-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmu
lt0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pa
rd\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\
sb119\sl-207\slmult0\fi0\tx2540 \up0 \expndtw-8\charscalex95 Figure 8.6\tab \up0
\expndtw-7\charscalex96 Illustration of a hearing instrument stethoscope used f
or a listening check.\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\s
l-240{\bkmkstart Pg211}{\bkmkend Pg211}\par\pard\li2996\sb0\sl-241\slmult0\par\p
ard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7208 \u
p0 \expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and Assisti
veTechnology\tab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 191\p
ar\pard\qj \li1286\sb0\sl-255\slmult0 \par\pard\qj\li1286\ri960\sb51\sl-255\slmu
lt0 \up0 \expndtw-9\charscalex94 performance quality, sales practices of hearing
health care practitioners, \line \up0 \expndtw-9\charscalex96 perception of hea
ring loss, and cost of the hearing instruments (Franks \line \up0 \expndtw-9\cha
rscalex92 & Beckmann, 1985; Kochkin, 1992, 1993, 1998; Mark, 2000). The
se \line \up0 \expndtw-10\charscalex93 conditions explain why assistive technolo
gy has become an increasingly \line \up0 \expndtw-9\charscalex94 feasible altern
ative for persons with (and without) hearing impairment. \par\pard\ql \li2854\sb

0\sl-276\slmult0 \par\pard\ql\li2854\sb112\sl-276\slmult0 \up0 \expndtw0\charsca

lex101 \ul0\nosupersub\cf7\f8\fs24 ASSISTIVE TECHNOLOGY \par\pard\qj \li1286\ri9
59\sb258\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\
f3\fs22 The Technology-Related Assistance for Individuals with Disabilities \lin
e \up0 \expndtw-9\charscalex91 Act of 1988 (U.S. Public Law 100 - 407), otherwis
e known as the Tech Act, \line \up0 \expndtw-9\charscalex93 denes assistive techn
ology as\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22
any item, piece of equipment or product \line \up0 \expndtw-10\charscalex95 sys
tem, whether acquired commercially o the shelf, modied or custo-\line \up0 \expndt
w-9\charscalex93 mized, that is used to increase or improve functional
capabilities of \line \up0 \expndtw-9\charscalex97 individuals with disabilitie
s.\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 The T
ech Act provides funding to develop \line \up0 \expndtw-10\charscalex96 statewid
e, consumer-responsive information and training programs \line \up0 \expndt
w-9\charscalex95 designed to meet the assistive technology needs of individuals
with dis-\line \up0 \expndtw-9\charscalex94 abilities. Just as with hearing inst
ruments, assistive technology serves to \line \up0 \expndtw-9\charscalex95 incre
ase independence of persons with disabilities and can further \line \up0
\expndtw-10\charscalex96 improve communicative functioning, because benets are o
btained by \line \up0 \expndtw-9\charscalex100 either enhancing listening abilit
y or by capitalizing on modalities other \line \up0 \expndtw-10\charscalex94 tha
n hearing. As the number of persons in need of assistive technology \line \up0 \
expndtw-9\charscalex91 has grown, the industry that designs, produces, and marke
ts these devices \line \up0 \expndtw-10\charscalex91 has grown substantially as
well. \par\pard\ql \li2866\sb0\sl-207\slmult0 \par\pard\ql\li2866\sb197\sl-207\s
lmult0 \up0 \expndtw0\charscalex107 \ul0\nosupersub\cf7\f8\fs24 E\ul0\nosupersub
\cf31\f32\fs17 NHANCING\ul0\nosupersub\cf7\f8\fs24 L\ul0\nosupersub\cf31\f32\fs
17 ISTENING\ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 BILITY \p
ar\pard\qj \li1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri959\sb10\sl-260\slmu
lt0\fi478 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Assistive te
chnology in the form of an FM amplication system \line \up0 \expndtw-9\charscalex
94 can be used to overcome limitations imposed by persons with and \li
ne \up0 \expndtw-5\charscalex100 without hearing impairment. In the United State
s, FM amplication \line \up0 \expndtw-10\charscalex93 systems are sanctioned by t
he Federal Communications Commission, a \line \up0 \expndtw-10\charscalex95 Unit
ed States government agency that regulates radiofrequency usage \line \up0 \expn
dtw-9\charscalex94 to broadcast on two designated radio frequency bands:
72^76 MHz \line \up0 \expndtw-10\charscalex95 and 216 ^217 MHz. The FM amplicat
ion system can transmit sounds \line \up0 \expndtw-9\charscalex100 anywhere from
30 to 200 feet. This provides users of this technology \line \up0 \expndtw-10\
charscalex95 with the ability to comprehend spoken messages in the presence
of \line \up0 \expndtw-9\charscalex96 competing noise, even when the listener i
s not in close proximity to the \line \up0 \expndtw-10\charscalex89 person speak
ing.
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212}{\bkmkend Pg212}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2656 \up0 \expndtw-10\char
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lt0\fi478 \up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\f3\fs22 Although a
number of dierent commercial FM amplication \line \up0 \expndtw-9\charscalex
93 systems are available, they usually consist of a basic set of components: \li
ne \up0 \expndtw-10\charscalex96 a microphone, a transmitter, and a receiver. Th
e personal FM receiver \line \up0 \expndtw-9\charscalex93 worn by the listener m
ust be set to the same channel and radiofrequency \line \up0 \expndtw-10\charsca
lex94 as the microphone/transmitter worn by the person speaking. The micro-\line
\up0 \expndtw-9\charscalex98 phone is oered in several styles, including lavalie
re, lapel, and boom. \line \up0 \expndtw-10\charscalex95 Lavaliere microphones a
re small and are usually positioned around the \line \up0 \expndtw-9\charscalex9
2 neck of the person speaking. Lapel microphones are typically clipped to a \lin
e \up0 \expndtw-9\charscalex96 pocket, tie, or lapel of the person speaking, and
the microphone should \line \up0 \expndtw-10\charscalex91 be placed approximate
ly 6 inches away from the person\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupe
rsub\cf2\f3\fs22 s mouth. Jewelry \line \up0 \expndtw-7\charscalex100 or other l
oose items that could rub or bump against the microphone \line \up0 \expndtw-10\
charscalex94 should be removed before use. Another option is the boom microphone
\line \up0 \expndtw-9\charscalex93 that is worn on the head, secured by a headb
and. The transmitter is worn \line \up0 \expndtw-9\charscalex100 by the person s
peaking and is small enough to be placed in a pocket. \line \up0 \expndtw-9\char
scalex97 The receiver is typically worn by the listener in a chest harness or on
a \line \up0 \expndtw-10\charscalex97 belt with individual FM systems. \par\par
d\qj \li1551\ri694\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex96 Two ty
pes of FM amplication systems are commonly used: indi-\line \up0 \expndtw-10\char
scalex93 vidual FM systems and sound-eld FM systems. Individual amplication \line
\up0 \expndtw-9\charscalex100 systems can be further grouped into two categories
: a self-contained \line \up0 \expndtw-9\charscalex100 system and a personal FM
system. The dierence between these two \line \up0 \expndtw-9\charscalex100 types
of individual systems depends on how the sound is delivered to \line \up0 \expnd
tw-9\charscalex94 the listener\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupers
ub\cf2\f3\fs22 s ears. A self-contained amplication system, also known as \line \
up0 \expndtw-9\charscalex97 an auditory trainer, typically delivers sound throug
h earphones. A self-\line \up0 \expndtw-9\charscalex95 contained auditory train
er amplication system is shown in Fig. 8.7. \line \up0 \expndtw-9\charscale
x96 Sounds are channeled from the environment to the receiver control \lin
e \up0 \expndtw-10\charscalex94 box and into the headphones. The receiver unit c
ontains environmental \line \up0 \expndtw-10\charscalex96 microphones and volume
control dials, allowing the user to control the \line \up0 \expndtw-9\charscale
x93 level of amplication. If the listener has a hearing loss and wears hearing \l
ine \up0 \expndtw-9\charscalex94 aids, then he or she is required to remove them
when using this system. \line \up0 \expndtw-10\charscalex94 Most individuals wh
o use the self-contained system have severe to pro-\line \up0 \expndtw-10\charsc
alex95 found hearing impairments; however, individuals with lesser degrees of \l
ine \up0 \expndtw-7\charscalex100 hearing loss and no hearing aids can benet from
using an auditory \line \up0 \expndtw-10\charscalex89 trainer as well (Flexer,
1999). \par\pard\qj \li1551\ri696\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\char
scalex96 A personal FM amplication system is similar to the auditory \line
\up0 \expndtw-9\charscalex95 trainer. The only dierence is that this system is c
oupled with a person\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\
fs22 s \line \up0 \expndtw-9\charscalex92 own hearing aid. A personal FM amplicat
ion system is shown in Fig. 8.8. \line \up0 \expndtw-8\charscalex100 Sounds are
channeled from the hearing aid through the FM system, \line \up0 \expndtw-8\char
scalex100 making this system dependent on the integrity of hearing instrument
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Pg213}\par\pard\li1286\sb0\sl-241\slmult0\par\pard\li1286\sb0\sl-241\slmult0\pa
r\pard\li1286\sb201\sl-241\slmult0\fi1709\tx7213 \up0 \expndtw-8\charscalex96 \u
l0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \up0 \expndt
w-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 193\par\pard\li1286\sb0\sl-207\slm
ult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\p
ard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286
\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-20
7\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\
par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\l
i1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\
sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slm
ult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\p
ard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286
\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-20
7\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\
par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\l
i1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\
sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slm
ult0\par\pard\li1286\sb0\sl-207\slmult0\par\pard\li1286\sb0\sl-207\slmult0\par\p
ard\li1286\sb8\sl-207\slmult0\fi0\tx2285 \up0 \expndtw-8\charscalex96 \ul0\nosup
ersub\cf5\f6\fs18 Figure 8.7\tab \up0 \expndtw-8\charscalex96 A self-contained (
auditory trainer) amplication system.\par\pard\sect\sectd\fs24\paperw8700\paperh1
3020{\shp
{\*\shpinst\shpleft0\shptop0\shpright8700\shpbottom13020\shpwr3\shpfblwtxt0\shpz
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rd\sb0\sl-240{\bkmkstart Pg214}{\bkmkend Pg214}\par\pard\li1551\sb0\sl-253\slmul
t0\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\t
x2656 \up0 \expndtw-10\charscalex97 \ul0\nosupersub\cf2\f3\fs22 194\tab \up0 \ex
pndtw-8\charscalex97 \ul0\nosupersub\cf5\f6\fs18 Alternative Communication, Ampl
ification, and Counseling\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0
\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\sl
mult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\
pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li155
1\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-2

07\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0
\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\
li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0
\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\sl
mult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\
pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li155
1\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-2
07\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0
\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\
li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb9
8\sl-207\slmult0\fi0\tx2640 \up0 \expndtw-7\charscalex100 Figure 8.8\tab \up0 \
expndtw-7\charscalex100 A personal FM amplication system with charger. (Repr
inted with\par\pard\li1551\sb13\sl-207\slmult0\fi0 \up0 \expndtw-7\charscalex10
0 permission from Phonic Ear, Inc.)\par\pard\sect\sectd\fs24\paperw8700\paperh13
020\pard\sb0\sl-240{\bkmkstart Pg215}{\bkmkend Pg215}\par\pard\li2996\sb0\sl-241
\slmult0\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb201\sl-241\slmult0
\fi0\tx7208 \up0 \expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 Amplificati
on and AssistiveTechnology\tab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2
\f3\fs22 195\par\pard\qj \li1286\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb
45\sl-258\slmult0 \up0 \expndtw-9\charscalex94 function. Coupling options for pe
rsonal FM amplication systems include \line \up0 \expndtw-9\charscalex91 neckloop
, silhouette, and DAI. Each coupling arrangement has advantages \line \up0 \expn
dtw-10\charscalex92 and disadvantages, and these dierences should be considered w
hen the \line \up0 \expndtw-9\charscalex98 clinician chooses an option for the i
ndividual with hearing impairment. \line \up0 \expndtw-5\charscalex100 The neckl
oop coupling option is a wire or loop that is worn loosely \line \up0 \expndtw-9
\charscalex96 around the listener\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosup
ersub\cf2\f3\fs22 s neck and is attached to the FM receiver. The wire \line \up0
\expndtw-9\charscalex91 receives the electrical signal and generates an electro
magnetic eld that is \line \up0 \expndtw-9\charscalex91 picked up by the person\u
l0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s hearing aid whe
n the aid is set to the telecoil\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul
0\nosupersub\cf2\f3\fs22 T\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \line \up
0 \expndtw-9\charscalex98 \ul0\nosupersub\cf2\f3\fs22 setting. An advantage to u
sing the neckloop tting is that there are no \line \up0 \expndtw-9\charscalex100
connecting wires between the receiver and the hearing aid. Also, the \line \up0
\expndtw-9\charscalex91 neckloop can be worn under clothes, reducing the cosmeti
c concern asso-\line \up0 \expndtw-9\charscalex100 ciated with use of amplication
devices. Potential drawbacks with the \line \up0 \expndtw-10\charscalex93 neckl
oop arrangement are increased equipment noise with this coupling \line \up0 \exp
ndtw-10\charscalex92 option and eects on signal strength with changes in head pos
itioning. \par\pard\qj \li1286\ri959\sb1\sl-260\slmult0\fi478 \up0 \expndtw-7\ch
arscalex100 As mentioned earlier, the biggest advantage to use of the BTE \line
\up0 \expndtw-9\charscalex95 hearing instrument is its DAI coupling to a persona
l FM system capabil-\line \up0 \expndtw-9\charscalex95 ity. W|th the DAI coup
ling option, mechanical interfaces have been \line \up0 \expndtw-6\charscal
ex100 developed to allow users to combine their BTEs with a personal or \line \u
p0 \expndtw-10\charscalex97 sound-eld FM amplication system. The electrical signal
from an FM \line \up0 \expndtw-9\charscalex92 receiver is directed into the hea
ring aid through an audio\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosup
ersub\cf2\f3\fs22 shoe\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersu
b\cf2\f3\fs22 or\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2
\f3\fs22 boot.\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \line \up0 \expndtw-1
0\charscalex97 \ul0\nosupersub\cf2\f3\fs22 These boots come in various shapes an
d must be tted snugly on the \line \up0 \expndtw-10\charscalex98 hearing aid to
minimize signal disruption. Figure \up0 \expndtw-10\charscalex79 8.9 \up0 \
expndtw-10\charscalex91 illustrates the \par\pard\qj \li1286\ri960\sb4\sl-256\s
lmult0 \up0 \expndtw-7\charscalex100 coupling of a BTE hearing instrument to a r
eceiver of a wireless FM \up0 \expndtw-9\charscalex94 system. This arrangement
allows wireless connection capability with \up0 \expndtw-9\charscalex94 sev

eral dierent BTE hearing instruments currently available on the \up0 \exp
ndtw-8\charscalex100 market. Key to its e\u8260?cient use is the presence on the
hearing aid of a \up0 \expndtw-9\charscalex93 special DAI feature that allows a
ccommodation of the boot; this feature is \up0 \expndtw-10\charscalex94 availabl
e on many BTE hearing instruments and on a limited number of \up0 \expndtw-10\ch
arscalex95 ITE hearing instruments. \par\pard\qj \li1286\ri960\sb1\sl-260\slmult
0\fi478 \up0 \expndtw-8\charscalex100 Unlike individual FM amplication system
s, sound-eld FM \line \up0 \expndtw-9\charscalex91 systems allow everyone withi
n an entire area, such as a classroom setting, \line \up0 \expndtw-10\charscalex
96 to benet from amplication. A sound-eld FM amplication system is \line \up0 \expnd
tw-8\charscalex100 shown in Fig. 8.10. In this case there is no need for the mic
rophone/ \line \up0 \expndtw-9\charscalex92 transmitter and receiver to be s
et to the same channel. Instead, the \line \up0 \expndtw-10\charscalex96 s
peech signal delivered into the microphone/transmitter by the person \line \up0
\expndtw-9\charscalex92 speaking is amplied and routed to loudspeakers pla
ced around the \line \up0 \expndtw-10\charscalex94 room. The use of a wireless
microphone by the person speaking allows \line \up0 \expndtw-9\charscalex95 add
itional mobility. W|th sound-eld FM amplication, the speaker\ul0\nosupersub\c
f11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s
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d\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2657 \up0
\expndtw-10\charscalex97 \ul0\nosupersub\cf2\f3\fs22 196\tab \up0 \expndtw-8\ch
arscalex97 \ul0\nosupersub\cf5\f6\fs18 Alternative Communication, Amplification,
and Counseling\par\pard\qj \li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\s
l-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-22
0\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\
slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\sl
mult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmu
lt0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult
0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0
\par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \p
ar\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par
\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\p
ard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\par
d\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\
qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj
\li1551\sb0\sl-220\slmult0 \par\pard\qj\li1551\sb0\sl-220\slmult0 \par\pard\qj\l
i1551\ri729\sb63\sl-220\slmult0\tx2552 \up0 \expndtw-6\charscalex100 Figure 8.9
\tab \up0 \expndtw-7\charscalex97 A behind-the-ear^style hearing instrument coup
led with an audio\ul0\nosupersub\cf10\f11\fs18 \u8216?\u8216?\ul0\nosupersub\cf
5\f6\fs18 shoe\ul0\nosupersub\cf10\f11\fs18 \u8217?\u8217? \line\up0 \expndtw-7\
charscalex97 \ul0\nosupersub\cf5\f6\fs18 and a wireless FM receiver. (Reprinted
with permission from Phonak Ear, Inc.) \par\pard\sect\sectd\fs24\paperw8700\pape
rh13020{\shp
{\*\shpinst\shpleft0\shptop0\shpright8700\shpbottom13020\shpwr3\shpfblwtxt0\shpz
-10000\shplid216
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}\pard\sb0\sl-240{\bkmkstart Pg217}{\bkmkend Pg217}\par\pard\li2996\sb0\sl-241\s
lmult0\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb201\sl-241\slmult0\f
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16 \up0 \expndtw-6\charscalex100 \ul0\nosupersub\cf5\f6\fs18 Figure 8.10\tab \u

p0 \expndtw-6\charscalex100 A sound-eld FM amplication system. (Reprinted with pe
rmission\par\pard\li1286\sb11\sl-207\slmult0\fi0 \up0 \expndtw-6\charscalex100 f
rom Phonic Ear, Inc.)\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\s
l-240{\bkmkstart Pg218}{\bkmkend Pg218}\par\pard\li1551\sb0\sl-253\slmult0\par\p
ard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2657 \u
p0 \expndtw-10\charscalex97 \ul0\nosupersub\cf2\f3\fs22 198\tab \up0 \expndtw-8\
charscalex97 \ul0\nosupersub\cf5\f6\fs18 Alternative Communication, Amplificatio
n, and Counseling\par\pard\qj \li1551\sb0\sl-250\slmult0 \par\pard\qj\li1551\ri6
96\sb88\sl-250\slmult0 \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22
voice can be raised at least 10 ^15 dB above the surrounding ambient \line \up
0 \expndtw-9\charscalex100 noise, improving the signal-to-noise ratio and enabli
ng greater under-\line \up0 \expndtw-10\charscalex92 standing of what is being s
aid (Crandell, Smaldino, & Flexer, 1995). \par\pard\qj \li1551\ri697\sb2\sl-260\
slmult0\fi478 \up0 \expndtw-10\charscalex92 Battery chargers also need to be con
sidered when FM amplication \line \up0 \expndtw-9\charscalex91 systems are used.
Optimal function is obtained when the batteries for both \line \up0 \expndtw-9\c
harscalex94 the FM transmitter and the FM receiver are charged regularly. The ch
ar-\line \up0 \expndtw-9\charscalex94 ging units are plugged into a standard wal
l socket, and the time required \line \up0 \expndtw-9\charscalex93 for charging
will vary from 8 to 12 hours. Battery chargers are available in \line \up0 \expn
dtw-9\charscalex89 three main types: case chargers, modular chargers, and wall c
hargers. Case \line \up0 \expndtw-10\charscalex95 chargers include spaces for 12
charging units. Modular chargers are 2-\line \up0 \expndtw-10\charscalex93 pock
et chargers but can be expanded by adding up to 12 more pockets. \line \up0 \exp
ndtw-10\charscalex94 Wall types allow for charging both transmitter and receiver
pairs. \par\pard\qj \li1551\ri694\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\cha
rscalex95 Induction loop amplication systems are another form of assistive \line
\up0 \expndtw-9\charscalex100 technology that can be used to overcome limitation
s imposed by less \line \up0 \expndtw-6\charscalex100 than ideal listening condi
tions for persons with and without hearing \line \up0 \expndtw-9\charscalex100 i
mpairment. The properties of induction loop amplication are similar \line \up0 \e
xpndtw-9\charscalex92 to those of a public address system. Speech directed into
a microphone is \line \up0 \expndtw-9\charscalex96 amplied and fed into a wire th
at is routed around a designated area of \line \up0 \expndtw-9\charscalex88 spac
e. The area of space creates a looped eld and may be as limited as the \line \up0
\expndtw-10\charscalex96 immediate circumference around an individual or as lar
ge as a seating \line \up0 \expndtw-9\charscalex95 section in an auditorium, chu
rch, or theater. The system works by trans-\line \up0 \expndtw-10\charscalex94 d
ucing the acoustic properties from speech spoken into the microphone \line \up0
\expndtw-10\charscalex96 to electromagnetic energy conducted through the wire. P
ersons sitting \line \up0 \expndtw-8\charscalex100 within the looped eld can rece
ive sound naturally through the loud-\line \up0 \expndtw-9\charscalex93 speakers
in the environment or via the electromagnetic signal by wearing \line \up0 \exp
ndtw-10\charscalex93 amplication that is sensitive to magnetic \up0 \expndtw
-10\charscalex89 eld changes, such as a \par\pard\ql \li1551\sb7\sl-253\slmul
t0 \up0 \expndtw-10\charscalex94 T-switch on a hearing instrument or personal FM
receiver. \par\pard\qj \li1551\ri694\sb2\sl-260\slmult0\fi478 \up0 \expndtw-10\
charscalex92 Infrared systems are a wireless type of assistive technology used t
o \line \up0 \expndtw-9\charscalex95 transmit signals by invisible light waves t
o the listener. The system con-\line \up0 \expndtw-9\charscalex95 sists of a tra
nsmitter, called an emitter, and a receiver that has an\ul0\nosupersub\cf11\f12\
fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 eye\ul0\nosupersub\cf11\f12\fs22
\u8217?\u8217? \line \up0 \expndtw-9\charscalex95 \ul0\nosupersub\cf2\f3\fs22 (
diode) on it. For the system to function properly, the diode picks up the \line
\up0 \expndtw-10\charscalex97 light waves from the emitter and converts them to
sound. Any number \line \up0 \expndtw-9\charscalex94 of receivers can be used wi
th the emitter, as long as each diode is within \line \up0 \expndtw-8\charscalex
100 the line of sight of the emitter (Crandell et al., 1995). A factor that can
\line \up0 \expndtw-9\charscalex97 inhibit the performance of an infrared system

is the amount of interfer-\line \up0 \expndtw-6\charscalex100 ence caused by li

ghting within the room as well as natural sunlight. \line \up0 \expndtw-9\charsc
alex100 Direct sunlight contains a large amount of infrared light and can block
\line \up0 \expndtw-10\charscalex94 the signal if the sunlight shines directly o
n the receiver diode.
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41\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7201 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \u
p0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 199\par\pard\qj \li1286\
sb0\sl-256\slmult0 \par\pard\qj\li1286\ri960\sb49\sl-256\slmult0\fi478 \up0 \exp
ndtw-9\charscalex100 Other types of assistive technology can be used to enhance
the \line \up0 \expndtw-9\charscalex93 speaker-to-listener conduit and are suita
ble for most clients regardless of \line \up0 \expndtw-8\charscalex100 their he
aring ability. They include wake-up alarms and amplied \line \up0 \expndtw
-9\charscalex100 cordless, cell, digital, and hard-wired telephones. W|th most s
tandard \line \up0 \expndtw-9\charscalex94 telephones, the user is not able
to change the volume level. When \line \up0 \expndtw-9\charscalex94 additi
onal amplication is necessary, an amplied telephone (Fig. 8.11) \line \up0 \expnd
tw-10\charscalex94 can allow for a range of \up0 \expndtw-10\charscalex94 3
0 to 50 dB of gain. Amplied phones \par\pard\qj \li1286\ri962\sb1\sl-260\s
lmult0 \up0 \expndtw-9\charscalex96 have additional features such as large
dialing buttons, moderately \up0 \expndtw-9\charscalex95 sized LCD screens,
and strobe ring signalers, making it easier for \up0 \expndtw-9\charsca
lex95 use when numbers are dialed or emitting ashing lights when the \u
p0 \expndtw-10\charscalex91 telephone rings. \par\pard\ql \li1753\sb0\sl-207\slm
ult0 \par\pard\ql\li1753\sb0\sl-207\slmult0 \par\pard\ql\li1753\sb150\sl-207\slm
ult0 \up0 \expndtw0\charscalex107 \ul0\nosupersub\cf7\f8\fs24 C\ul0\nosupersub\c
f31\f32\fs17 APITALIZING ON\ul0\nosupersub\cf7\f8\fs24 M\ul0\nosupersub\cf31\f3
2\fs17 ODALITIES\ul0\nosupersub\cf7\f8\fs24 O\ul0\nosupersub\cf31\f32\fs17 THER
\ul0\nosupersub\cf7\f8\fs24 T\ul0\nosupersub\cf31\f32\fs17 HAN\ul0\nosupersub\c
f7\f8\fs24 H\ul0\nosupersub\cf31\f32\fs17 EARING \par\pard\qj \li1286\sb0\sl-25
8\slmult0 \par\pard\qj\li1286\ri959\sb13\sl-258\slmult0\fi478 \up0 \expndtw-10\c
harscalex96 \ul0\nosupersub\cf2\f3\fs22 Assistive communication devices that do
not emphasize listening \line \up0 \expndtw-9\charscalex100 ability include tele
communication devices for the deaf (TDD), compu-\line \up0 \expndtw-9\charscalex
92 terized speech recognition programs, closed caption decoders, and visual \lin
e \up0 \expndtw-9\charscalex91 alerting devices. These types of assistive techno
logy go as far back as the \line \up0 \expndtw-10\charscalex96 1960s, when telep
hone modems were rst linked with telephone type-\line \up0 \expndtw-10\charscalex
97 writers (TTYs), enabling persons with hearing impairment to converse \line \u
p0 \expndtw-8\charscalex100 via phone lines by typing conversations back and for
th (Rothstein & \line \up0 \expndtw-9\charscalex90 Everson, 1995). Today, compu
terized speech recognition systems, desktop \line \up0 \expndtw-9\charscalex94 c
omputers, and laptop computers have the ability to provide audio trans-\line \up
0 \expndtw-9\charscalex97 mission or display textual versions of speech in real
time. Because the \line \up0 \expndtw-10\charscalex94 computerized speech recogn
ition system is congured as a best t of a \line \up0 \expndtw-9\charscalex98 lingu
istic parse, the textual on-screen presentation may dier from the \line \up0 \exp

ndtw-9\charscalex95 speaker\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\

cf2\f3\fs22 s actual utterances, depending on factors of dialect, format fre-\li
ne \up0 \expndtw-10\charscalex97 quencies, and the actual computer program itsel
f (Molnar et al., 2000; \line \up0 \expndtw-9\charscalex93 Sutton, 1997). For
these reasons, there may be situations in which \line \up0 \expndtw-8\ch
arscalex100 the individual and his or her speaking partner may need to repair th
e \line \up0 \expndtw-10\charscalex90 conversation on occasion. \par\pard\qj \li
1286\ri960\sb1\sl-260\slmult0\fi478 \up0 \expndtw-7\charscalex100 Alerting devic
es display a visual or tactile signal when a sound \line \up0 \expndtw-9\charsca
lex95 occurs. The alerting system may be a strobe light, conventional light, or
\line \up0 \expndtw-6\charscalex100 ashing light. If vision is poor, vibrating pa
ges or a service dog can \line \up0 \expndtw-9\charscalex98 alert the client. Al
though several organizations provide these animals, \line \up0 \expndtw-10\chars
calex94 Canine Companions for Independence (www.caninecompanions.org) is \line \
up0 \expndtw-10\charscalex95 a 501(c)(3) nonprot organization that serves to enh
ance the lives of
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, Amplification, and Counseling\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li15
51\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult
0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard
\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb
0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\s
lmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par
\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li15
51\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult
0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard
\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb
0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\s
lmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par
\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li15
51\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb0\sl207\slmult0\par\pard\li1551\sb0\sl-207\slmult0\par\pard\li1551\sb106\sl-207\slmu
lt0\fi0\tx2612 \up0 \expndtw-7\charscalex100 Figure 8.11\tab \up0 \expndtw-7\cha
rscalex100 Illustration of an amplied telephone. (Reprinted with permission from\
par\pard\li1551\sb13\sl-207\slmult0\fi0 \up0 \expndtw-7\charscalex100 HITEC Grou
p International, Inc.)\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\
sl-240{\bkmkstart Pg221}{\bkmkend Pg221}\par\pard\li2996\sb0\sl-241\slmult0\par\
pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7192 \
up0 \expndtw-8\charscalex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and Assist
iveTechnology\tab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 201\
par\pard\qj \li1286\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri960\sb45\sl-258\slm
ult0 \up0 \expndtw-9\charscalex96 people with disabilities by providing highly t
rained assistance dogs and \line \up0 \expndtw-9\charscalex93 ongoing support to
ensure quality partnerships. Founded in 1975, Canine \line \up0 \expndtw-10\cha
rscalex93 Companions for Independence pioneered the concept of training dogs to
\line \up0 \expndtw-9\charscalex91 assist people with physical disabilities. An
assistance dog is trained to help \line \up0 \expndtw-8\charscalex100 its owner
deal with physical obstacles in daily life as well as signal its \line \up0 \exp
ndtw-10\charscalex91 owner to environmental sounds such as smoke alarms, telepho
nes, door-\line \up0 \expndtw-9\charscalex92 bells, and clock alarms. People wit
h physical or developmental disabilities \line \up0 \expndtw-9\charscalex100 who
can demonstrate that a trained assistance dog will enhance their \line \up0 \ex
pndtw-5\charscalex100 independence or their quality of life are eligible to appl
y at regional \line \up0 \expndtw-9\charscalex93 centers throughout the Unite
d States. Also eligible are professionals \line \up0 \expndtw-9\charscalex9
6 working for organizations that provide physical or mental health care to \line
\up0 \expndtw-10\charscalex94 clients who could benet, and there is usually no c
harge for the dog. \par\pard\ql \li2698\sb0\sl-207\slmult0 \par\pard\ql\li2698\s
b0\sl-207\slmult0 \par\pard\ql\li2698\sb151\sl-207\slmult0 \up0 \expndtw0\charsc
alex101 \ul0\nosupersub\cf7\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 ELECTING\ul0\
nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 SSISTIVE\ul0\nosupersub\c
f7\f8\fs24 T\ul0\nosupersub\cf31\f32\fs17 ECHNOLOGY \par\pard\qj \li1286\sb0\sl
-258\slmult0 \par\pard\qj\li1286\ri959\sb13\sl-258\slmult0\fi478 \up0 \expndtw-1
0\charscalex91 \ul0\nosupersub\cf2\f3\fs22 Selection of assistive technology oft
en occurs by conducting a func-\line \up0 \expndtw-9\charscalex98 tional assessm
ent of the potential user\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf

2\f3\fs22 s abilities. Hearing impairment \line \up0 \expndtw-6\charscalex100 (i

f any) along with limitations in cognitive or physical abilities should \line \u
p0 \expndtw-9\charscalex100 be documented. When functional needs are queried, in
dividuals may \line \up0 \expndtw-7\charscalex100 report subjective complaints s
imilar to those of individuals in need of \line \up0 \expndtw-9\charscalex95 hea
ring instruments; that is, saying that others are constantly mumbling \line \up0
\expndtw-9\charscalex95 during conversations, having the ability to hear and no
t fully understand \line \up0 \expndtw-9\charscalex94 what others are saying, ha
ving to turn up the volume on the television or \line \up0 \expndtw-9\charscalex
96 radio to the point at which other family members complain, or reporting \line
\up0 \expndtw-8\charscalex100 that excessive noise in the environment limits th
e amount of speech \line \up0 \expndtw-10\charscalex95 understanding. However, t
hese individuals may be adamantly opposed \line \up0 \expndtw-9\charscalex93 to
hearing aid use as an option, which is why assistive technology serves \line \up
0 \expndtw-10\charscalex87 as a feasible alternative. \par\pard\qj \li1286\ri959
\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 Subsequent to the functi
onal assessment, it is important to deter-\line \up0 \expndtw-6\charscalex100 mi
ne the number of environments in which the user will need the \line \up0 \exp
ndtw-8\charscalex100 assistive technology. W|thin this realm, a determination of
the actual \line \up0 \expndtw-7\charscalex100 tasks the person will have
to perform in terms of job function, \line \up0 \expndtw-6\charscalex100 a
ctivities of daily living, leisure activities, or otherwise is crucial. For \lin
e \up0 \expndtw-9\charscalex95 instance, using the assistive technology may
require the individual \line \up0 \expndtw-5\charscalex100 to implement mo
dications in his or her lifestyle for academic \line \up0 \expndtw-9\chars
calex100 or employment purposes. Use of an FM amplication system is often \line \
up0 \expndtw-9\charscalex100 considered as a component of habilitation or rehabi
litation to promote
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
222}{\bkmkend Pg222}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2662 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 202\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri694\sb70\sl-260\slmu
lt0 \up0 \expndtw-9\charscalex96 \ul0\nosupersub\cf2\f3\fs22 academic success
in a child with hearing impairment, and written \line \up0 \expndtw-7\cha
rscalex100 recommendations in an individualized education plan are often
\line \up0 \expndtw-7\charscalex100 made on the type of amplication system a chil
d should use (i.e., a \line \up0 \expndtw-9\charscalex94 personal or sound-eld
amplication system). Once this occurs, the \line \up0 \expndtw-10\charscal
ex96 chosen amplication system is usually purchased either by the school \line \u
p0 \expndtw-10\charscalex97 or the district in which the school resides \
up0 \expndtw-10\charscalex93 (K. Takekawa, personal \par\pard\ql \li1551\sb6\sl
-253\slmult0 \up0 \expndtw-10\charscalex92 communication, 2003). \par\pard\qj \l
i1551\ri694\sb0\sl-262\slmult0\fi478 \up0 \expndtw-10\charscalex96 After the num
ber of environments in which the user will need the \line \up0 \expndtw-9\charsc
alex94 assistive technology is determined, the clinician provides the appropriat
e \line \up0 \expndtw-10\charscalex95 technology to match the person\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s circumstance. Central to

the success \line \up0 \expndtw-7\charscalex100 in use of the assistive technolo

gy is choosing one that is not likely to \line \up0 \expndtw-8\charscalex100 bre
ak down, is relatively easy to use, and is durable for an extended \line \up0 \e
xpndtw-10\charscalex94 period. A complex technology may be more prone to being a
bandoned, \line \up0 \expndtw-9\charscalex95 especially if it is selected f
or someone with cognitive impairments. \line \up0 \expndtw-9\charscalex95 Th
is person may require an extended period to learn the full capabilities \line \u
p0 \expndtw-10\charscalex95 of the technology, or the technology may have extrem
ely delicate parts \line \up0 \expndtw-9\charscalex100 that can be easily damage
d. Finally, an important aspect to consider \line \up0 \expndtw-5\charscalex100
throughout this entire process is the role of signicant others. \line \
up0 \expndtw-9\charscalex93 Signicant others in this case refers to parents, spou
se, children, or care-\line \up0 \expndtw-7\charscalex100 giver, because they al
l play a important role in decision making and \line \up0 \expndtw-9\charscalex1
00 ensuring daily use. When in doubt, it may be a good idea to schedule \line \u
p0 \expndtw-9\charscalex96 consultations with an audiologist, vision specialist,
or other knowledge-\line \up0 \expndtw-9\charscalex91 able health care provi
ders before any type of assistive technology is \line \up0 \expndtw-10\ch
arscalex91 obtained. \par\pard\ql \li1984\sb0\sl-276\slmult0 \par\pard\ql\li1984
\sb0\sl-276\slmult0 \par\pard\ql\li1984\sb95\sl-276\slmult0 \up0 \expndtw0\chars
calex103 \ul0\nosupersub\cf7\f8\fs24 TRENDS IN AMPLIFICATION AND ASSISTIVE \par\
pard\ql \li3770\sb4\sl-276\slmult0 \up0 \expndtw0\charscalex103 TECHNOLOGY \par\
pard\qj \li1551\ri694\sb256\sl-262\slmult0\fi478 \up0 \expndtw-9\charscalex100 \
ul0\nosupersub\cf2\f3\fs22 Current habilitation or rehabilitation for persons wh
o are hard of \line \up0 \expndtw-6\charscalex100 hearing or deaf can take the f
orm of corrective surgery or provision \line \up0 \expndtw-9\charscalex93 of am
plication, assistive technology, or specialized support services \line \up0
\expndtw-9\charscalex94 such as interpreters or notetakers. Technology in the t
wenty-rst century \line \up0 \expndtw-9\charscalex96 for individuals with sensory
disability has advanced from low-end paper \line \up0 \expndtw-9\charscalex94 a
nd pencil communication boards and large bulky hardwire devices \line \u
p0 \expndtw-9\charscalex93 to more sophisticated computers and wireless te
chnology (Rothstein \line \up0 \expndtw-10\charscalex93 & Everson, 1995). Regar
dless of hearing status, most individuals with
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
223}{\bkmkend Pg223}\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\sl-2
41\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7194 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \u
p0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 203\par\pard\qj \li1286\
sb0\sl-257\slmult0 \par\pard\qj\li1286\ri959\sb47\sl-257\slmult0 \up0 \expndtw-5
\charscalex100 (or without) hearing impairment are not innately versed i
n the \line \up0 \expndtw-10\charscalex92 mechanics or the communication strate
gies needed for successful use of \line \up0 \expndtw-9\charscalex93 amplication
and assistive technology. One of the biggest problems \line \up0 \expndt
w-9\charscalex95 facing successful system use is lack of support as well as lack
of knowl-\line \up0 \expndtw-10\charscalex97 edge of the numerous options avail
able for improving communication. \line \up0 \expndtw-9\charscalex92 Many in the
general public assume that once the amplication or assistive \line \up0 \expndtw
-10\charscalex95 technology is provided, there is no longer a problem. This gap

between \line \up0 \expndtw-9\charscalex95 the lack of understanding and eecti

ve use of the equipment is the \line \up0 \expndtw-9\charscalex100 rationa
le behind the (re)habilitative patient management principles of \line \up0 \exp
ndtw-10\charscalex93 many orientation programs. \par\pard\qj \li1286\ri959\sb2\s
l-259\slmult0\fi478 \up0 \expndtw-10\charscalex97 Quality of life improvement in
terms of reducing a hearing handi-\line \up0 \expndtw-7\charscalex100 cap and i
mproving physical and mental health functioning are well-\line \up0 \expndtw-9\
charscalex94 established components of the rehabilitation process (Keith, 1994).
Most \line \up0 \expndtw-9\charscalex96 habilitation or rehabilitation programs
work to change the perception of \line \up0 \expndtw-10\charscalex94 what const
itutes a hearing handicap and to improve a person\ul0\nosupersub\cf11\f12\fs22 \
u8217?\ul0\nosupersub\cf2\f3\fs22 s physical \line \up0 \expndtw-8\charscalex100
and mental health functioning by furnishing educational materials on \line \up0
\expndtw-9\charscalex92 hearing loss, support counseling, amplication, and
assistive technol-\line \up0 \expndtw-9\charscalex95 ogy; setting realistic ex
pectations to assist in better communication; and \line \up0 \expndtw-9\charscal
ex96 developing assertive listening strategies to improve communication \l
ine \up0 \expndtw-10\charscalex96 (Abrahamson, 1991; Abrams, Hnath-Chisolm, Guer
reiro, & Ritterman, \line \up0 \expndtw-9\charscalex91 1992; Kricos, 1997; Lesne
r, 2003). This type of orientation process usually \line \up0 \expndtw-9\charsca
lex93 involves rst-time users of amplication, and the overall success of using \li
ne \up0 \expndtw-9\charscalex95 (re)habilitative eorts to maximize benet is closel
y related to the extent \line \up0 \expndtw-9\charscalex100 of the program. This
premise is based on the fact that programs vary \line \up0 \expndtw-9\charscale
x100 from individualized hearing aid and assistive technology instruction to \li
ne \up0 \expndtw-9\charscalex100 well-organized group environments that focus no
t only on the person \line \up0 \expndtw-9\charscalex96 with the hearing loss bu
t also on their spouses and signicant other(s). \line \up0 \expndtw-9\charscalex9
3 Resources that provide information about how amplication and assistive \line \u
p0 \expndtw-9\charscalex97 technology enable persons with disabilities to experi
ence full participa-\line \up0 \expndtw-9\charscalex94 tion in activities of dai
ly living are also available via the World W|de Web \line \up0 \expndtw-9\charsc
alex96 (www.loc.gov/nls) (National Library Service for the Blind and Physically
\line \up0 \expndtw-10\charscalex89 Handicapped, 2000). \par\pard\qj \li1286\ri9
60\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 Strategies that enha
nce communication include optimizing the \line \up0 \expndtw-9\charscalex94
environment and the speaker^listener relationship. To optimize the envi-\line \u
p0 \expndtw-9\charscalex95 ronment, there should be good signal-to-noise ratios,
increased lighting, \line \up0 \expndtw-10\charscalex96 and decreased reverbera
tion through the use of drapes and carpeting, \line \up0 \expndtw-9\charscalex95
because ambient noise can interfere with understanding of speech \line
\up0 \expndtw-10\charscalex95 (Crandell et al., \up0 \expndtw-10\charscalex95
1995). Similarly, to optimize the speaker^listener
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
224}{\bkmkend Pg224}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2666 \up0 \expndtw-10\char
scalex100 \ul0\nosupersub\cf2\f3\fs22 204\tab \up0 \expndtw-8\charscalex100 \ul0
\nosupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling
\par\pard\qj \li1551\sb0\sl-256\slmult0 \par\pard\qj\li1551\ri694\sb77\sl-256\sl

mult0 \up0 \expndtw-9\charscalex97 \ul0\nosupersub\cf2\f3\fs22 relationship, spe

akers should keep their mouths highly visible; provide \line \up0 \expndtw-10\ch
arscalex94 concise, highly redundant messages; speak slowly and clearly; indicat
e \line \up0 \expndtw-7\charscalex100 changes in topic; and be sensitive to the
fatigue level of the listener. \line \up0 \expndtw-9\charscalex95 Finally, all l
isteners should be self-advocates for improving communica-\line \up0 \expndtw-9\
charscalex95 tion, such as asking for their communication partner(s) to repeat m
issed \line \up0 \expndtw-10\charscalex89 pieces of the conversation and request
ing clarications as necessary. \par\pard\ql \li3767\sb0\sl-276\slmult0 \par\pard\
ql\li3767\sb232\sl-276\slmult0 \up0 \expndtw-1\charscalex100 \ul0\nosupersub\cf7
\f8\fs24 CONCLUSIONS \par\pard\qj \li1551\sb0\sl-258\slmult0 \par\pard\qj\li1551
\ri695\sb1\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf
2\f3\fs22 Despite improvements in technology and health care, the number \line \
up0 \expndtw-6\charscalex100 of individuals with disabilities and the complexity
of needs they and \line \up0 \expndtw-9\charscalex92 their families experienc
e continues to increase. In response to these \line \up0 \expndtw-10\char
scalex95 needs, specialized technology has been developed to help people with \l
ine \up0 \expndtw-9\charscalex94 disabilities become more independent and more i
nvolved in the activities \line \up0 \expndtw-10\charscalex93 in their homes, sc
hools, and communities (Berry and Ignash, 2003). The \line \up0 \expndtw-9\chars
calex96 usefulness of amplication and assistive technology for individuals with \
line \up0 \expndtw-10\charscalex96 hearing impairment depends greatly on the
type of communication \line \up0 \expndtw-9\charscalex95 needed and on the
amount of residual hearing ability. The service \line \up0 \expndtw-8\cha
rscalex100 system for people with disabilities has changed from an institutional
-\line \up0 \expndtw-9\charscalex94 based medical model to a more collaborative
habilitation or rehabilitation \line \up0 \expndtw-10\charscalex93 model, and mo
re attention should be given to developing and supporting \line \up0 \expndtw-9\
charscalex96 the providers involved. For instance, even a mild hearing loss in a
child \line \up0 \expndtw-10\charscalex92 can sabotage the development of acade
mic competencies, and there is a \line \up0 \expndtw-7\charscalex100 growing pop
ulation of school children with mild to moderate hearing \line \up0 \expndtw-9\c
harscalex92 loss (Hawkins, 1984; Hick and Tharpe, 2002). Unfortunately, there ar
e far \line \up0 \expndtw-10\charscalex97 too few audiologists employed in educa
tional settings (approximately \line \up0 \expndtw-9\charscalex97 700 nationall
y), with an average ratio of 1 audiologist for every 12,000 \line \up0 \expndtw9\charscalex92 children, but some audiologists have 100,000 children or more to
manage \line \up0 \expndtw-10\charscalex89 (Flexer, \up0 \expndtw-10\charscalex9
2 1990; K. Takekawa, personal communication, \up0 \expndtw-10\charscalex92 20
03; W|lson-\par\pard\ql \li1551\sb7\sl-253\slmult0 \up0 \expndtw-10\charscalex94
Vlotman & Blair, 1986). \par\pard\qj \li1551\ri694\sb2\sl-260\slmult0\fi478 \up
0 \expndtw-10\charscalex93 Besides identifying the impact of psychosocial,
economic, and \line \up0 \expndtw-9\charscalex97 physical factors on the patie
nt\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s perceived h
andicap, the clinician must \line \up0 \expndtw-9\charscalex95 also consider how
these factors inuence the best choice of hearing aid \line \up0 \expndtw-9\chars
calex98 styles and assistive technologies for the patient. Economic factors will
\line \up0 \expndtw-9\charscalex97 always play a pivotal role in determining wh
ether the client will be able \line \up0 \expndtw-9\charscalex92 to aord certain
hearing instruments or assistive technology. Psychosocial \line \up0 \expndtw-9\
charscalex92 factors such as the patient\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul
0\nosupersub\cf2\f3\fs22 s family support and personal self-concept can
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s

p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
225}{\bkmkend Pg225}\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\sl-2
41\slmult0\par\pard\li2996\sb201\sl-241\slmult0\fi0\tx7192 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Amplification and AssistiveTechnology\tab \u
p0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 205\par\pard\qj \li1286\
sb0\sl-255\slmult0 \par\pard\qj\li1286\ri961\sb51\sl-255\slmult0 \up0 \expndtw-1
0\charscalex97 also aect whether patients choose to use more sophisticated hearin
g \up0 \expndtw-9\charscalex100 instrument circuitry options. Failure to provide
adequate medical and \up0 \expndtw-9\charscalex94 other services for people wit
h disabilities can jeopardize their safety and \up0 \expndtw-8\charscalex100 hea
lth, and a good working relationship with the hearing health care \up0 \expndtw10\charscalex89 professional is a necessary component in this process. \par\pard
\ql \li3046\sb0\sl-276\slmult0 \par\pard\ql\li3046\sb112\sl-276\slmult0 \up0 \ex
pndtw0\charscalex102 \ul0\nosupersub\cf7\f8\fs24 ACKNOWLEDGMENTS \par\pard\qj \l
i1286\ri959\sb258\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex94 \ul0\nosupe
rsub\cf2\f3\fs22 The author acknowledges a number of persons who supplied data \
line \up0 \expndtw-9\charscalex97 or information used in the preparation of this
chapter: Michele Ahlman, \line \up0 \expndtw-10\charscalex92 Cynthia Armas, Jil
l Kanda, Jason Kaufman, Filiesha LeRand, Eva Leung, \line \up0 \expndtw-10\chars
calex96 Judith Mason, Kris Souza, Kristine Takekawa, Laura Voll, Joan Wylie, \li
ne \up0 \expndtw-10\charscalex97 Jamie Young, and Erin Zakahi. The Web sites pro
vided in the chapter \line \up0 \expndtw-9\charscalex96 were current at the time
the chapter was written. Because of the transi-\line \up0 \expndtw-9\charscalex
97 tory nature of Web sites, continued availability at the uniform resource \lin
e \up0 \expndtw-10\charscalex94 locators (URLs) mentioned herein is not guarante
ed. \par\pard\ql \li3576\sb0\sl-276\slmult0 \par\pard\ql\li3576\sb111\sl-276\slm
ult0 \up0 \expndtw-3\charscalex100 \ul0\nosupersub\cf7\f8\fs24 REFERENCES \par\p
ard\ql \li1286\sb0\sl-220\slmult0 \par\pard\ql\li1286\ri993\sb51\sl-220\slmult0\
fi0\tx1525\tx1525\tx1525 \up0 \expndtw-7\charscalex94 \ul0\nosupersub\cf5\f6\fs1
8 Abrahamson, J. (1991). Teaching coping strategies: A client education approach
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x100 Abrams, H., Hnath-Chisolm, T., Guerreiro, S., & Ritterman, S. (1992). Th
e eects \line\tab \up0 \expndtw-7\charscalex95 of intervention strategy on selfperception of hearing handicap. Ear and Hearing, 13, \line \tab \up0 \expndtw-8\
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5 \up0 \expndtw-7\charscalex97 Allen, J., Hall, J., & Jeng, P. (1990). Loudness
growth in 1/2-octave bands (LGOB) A \line\tab \up0 \expndtw-7\charscalex87 pro
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b \up0 \expndtw-8\charscalex93 Hearing Aid Society. \par\pard\qj \li1286\ri992\s
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pndtw-7\charscalex100 Byrne, D., & Tonisson, W. (1976). Selecting the gain of he
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arscalex97 Cornelisse, L., Seewald, R., & Jamieson, D. (1995). The input
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{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
226}{\bkmkend Pg226}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2666 \up0 \expndtw-10\char
scalex100 \ul0\nosupersub\cf2\f3\fs22 206\tab \up0 \expndtw-8\charscalex100 \ul0
\nosupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling
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{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz248\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
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227}{\bkmkend Pg227}\par\pard\li2996\sb0\sl-241\slmult0\par\pard\li2996\sb0\sl-2
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fessional \line\tab \up0 \expndtw-8\charscalex88 (2nd ed.). San Diego: Singular.
\par\pard\qj \li1286\ri994\sb0\sl-220\slmult0\tx1525 \up0 \expndtw-7\charscalex
98 W|lson-Vlotman, A. L., & Blair, J. C. (1986). A survey of audiologists workin
g full-time \line\tab \up0 \expndtw-8\charscalex91 in school systems. ASHA, 28,
33 ^38.

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-253\slmult0 \par\pard\ql\li1945\sb74\sl-253\slmult0 \up0 \expndtw-4\charscalex1
00 \ul0\nosupersub\cf2\f3\fs22 Mary Jean J. Dyczko, M.A., CCC/SLP, TSHH, ATP \pa
r\pard\ql \li2636\sb26\sl-230\slmult0 \up0 \expndtw-9\charscalex92 \ul0\nosupers
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\ql \li3780\sb10\sl-230\slmult0 \up0 \expndtw-4\charscalex100 New York, NY \par\
pard\ql \li1956\sb231\sl-253\slmult0 \up0 \expndtw-5\charscalex100 \ul0\nosupers
ub\cf2\f3\fs22 Nancy Lenhart Jones, M.S., CCC/SLP, TSHH, ATP \par\pard\ql \li263
6\sb26\sl-230\slmult0 \up0 \expndtw-9\charscalex92 \ul0\nosupersub\cf6\f7\fs20 N
YS Licensed Speech-Language Pathologist \par\pard\ql \li2327\sb10\sl-230\slmult0
\up0 \expndtw-9\charscalex97 RESNA Certified Assistive Technology Practitioner
\par\pard\ql \li1687\sb10\sl-230\slmult0 \up0 \expndtw-9\charscalex97 Practicing
Augmentative and Alternative Communication Specialist \par\pard\ql \li3780\sb10
\sl-230\slmult0 \up0 \expndtw-4\charscalex100 New York, NY \par\pard\ql \li2840\
sb0\sl-240\slmult0 \par\pard\ql\li2840\ri2284\sb102\sl-240\slmult0 \up0 \expndtw
0\charscalex100 What Is Augmentative and Alternative \up0 \expndtw0\charscalex10
0 Communication? \par\pard\ql \li2840\ri1577\sb6\sl-233\slmult0\tx3319\tx3319 \u
p0 \expndtw-2\charscalex100 What Affects theType of an Augmentative and \line \u
p0 \expndtw-2\charscalex100 Alternative Communication System? \line \tab \up0 \e
xpndtw-9\charscalex95 Receptive Language Skills and Cognition \line \tab \up0 \e
xpndtw-9\charscalex96 Vision Skills \par\pard\ql \li3319\sb10\sl-230\slmult0 \up
0 \expndtw-5\charscalex100 Auditory Skills \par\pard\ql \li3319\sb10\sl-230\slmu
lt0 \up0 \expndtw-9\charscalex92 Physical/Motor Issues \par\pard\ql \li2840\ri14
93\sb2\sl-240\slmult0 \up0 \expndtw0\charscalex100 Augmentative and Alternative
Communication \up0 \expndtw-9\charscalex96 Systems \par\pard\ql \li3319\sb9\sl-2
30\slmult0 \up0 \expndtw-9\charscalex95 Manual Communication Systems \par\pard\q
l \li2840\ri2316\sb2\sl-240\slmult0\fi478 \up0 \expndtw-9\charscalex95 Electroni
c Communication Systems \up0 \expndtw-2\charscalex100 Determining the Appropriat
eness \line \up0 \expndtw-2\charscalex100 of an Augmentative and Alternative \up
0 \expndtw-2\charscalex100 Communication System \par\pard\ql \li2840\sb9\sl-230\
slmult0 \up0 \expndtw0\charscalex100 Funding \par\pard\ql \li4267\sb0\sl-207\slm
ult0 \par\pard\ql\li4267\sb0\sl-207\slmult0 \par\pard\ql\li4267\sb0\sl-207\slmul
t0 \par\pard\ql\li4267\sb0\sl-207\slmult0 \par\pard\ql\li4267\sb0\sl-207\slmult0
\par\pard\ql\li4267\sb0\sl-207\slmult0 \par\pard\ql\li4267\sb167\sl-207\slmult0
\up0 \expndtw-8\charscalex90 \ul0\nosupersub\cf5\f6\fs18 209 \par\pard\qj \li30
67\ri2882\sb0\sl-160\slmult0\fi65 \up0 \expndtw0\charscalex100 \ul0\nosupersub\c
f30\f31\fs12 Aural Rehabilitation for People with Disabilities \line \up0 \expnd
tw0\charscalex100 Copyright \up0 \expndtw-2\charscalex100 2005, Elsevier Inc. Al
l rights reserved.

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}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
230}{\bkmkend Pg230}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2656 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 210\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\ql \li3106\sb0\sl-230\slmult0 \par\pard\ql\li3106\ri2324\sb104\sl-230\sl
mult0 \up0 \expndtw0\charscalex101 \ul0\nosupersub\cf6\f7\fs20 Training \line \u
p0 \expndtw0\charscalex102 Summary \line \up0 \expndtw-8\charscalex100 Reference
s \par\pard\ql \li3106\sb10\sl-230\slmult0 \up0 \expndtw-7\charscalex100 Selecte
d Readings \par\pard\qj \li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\sb0\sl-26
0\slmult0 \par\pard\qj\li1551\sb0\sl-260\slmult0 \par\pard\qj\li1551\ri695\sb66\
sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 C
ommunication is the transmission of one\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0
\nosupersub\cf2\f3\fs22 s thoughts, ideas, and \line \up0 \expndtw-9\charscalex1
00 wants to another individual or group of individuals. Communication is \line \
up0 \expndtw-9\charscalex92 typically expressed using speech, facial expressions
, body language, ges-\line \up0 \expndtw-7\charscalex100 tures, and written lett
ers or e-mails. Some individuals have di\u8260?culties \line \up0 \expndtw-9\cha
rscalex91 expressing their wants and needs through traditional means (i.e., spee
ch), \line \up0 \expndtw-9\charscalex91 and they require assistance for expressi
ng themselves. Various disabilities \line \up0 \expndtw-7\charscalex100 can aect
an individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s
ability to speak or write. Augmentative and \line \up0 \expndtw-10\charscalex94
alternative communication (AAC) systems are methods that are used to \line \up0
\expndtw-8\charscalex100 help individuals communicate more eectively. Therefore t
he goal of \line \up0 \expndtw-10\charscalex94 AAC is eective, quick, and accurat
e communication. \par\pard\ql \li1861\sb0\sl-276\slmult0 \par\pard\ql\li1861\sb0
\sl-276\slmult0 \par\pard\ql\li1861\sb195\sl-276\slmult0 \up0 \expndtw0\charscal
ex104 \ul0\nosupersub\cf7\f8\fs24 WHAT IS AUGMENTATIVE AND ALTERNATIVE \par\pard
\ql \li3501\sb4\sl-276\slmult0 \up0 \expndtw0\charscalex102 COMMUNICATION? \par\
pard\qj \li1551\ri696\sb258\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex96 \
ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 Individua
ls with severe communication disorders are those who \line \up0 \expndtw-10\char
scalex96 may benet from [AAC] those for whom gestural, speech and/or writ-\line
\up0 \expndtw-10\charscalex94 ten communication is temporarily or permanently i
nadequate to meet all \line \up0 \expndtw-10\charscalex95 of their communication
needs. . . \up0 \expndtw-10\charscalex95 . Although some of these individuals \

par\pard\qj \li1551\ri697\sb0\sl-260\slmult0 \up0 \expndtw-10\charscalex96 may b

e able to produce a limited amount of speech, it is inadequate to \line \up0 \ex
pndtw-10\charscalex94 meet their varied communication needs\ul0\nosupersub\cf11\
f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 (American Speech-Language \
line \up0 \expndtw-10\charscalex95 Hearing Association \up0 \expndtw-10\charsca
lex91 [ASHA], 1989, pp. 107^110).\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216
?\ul0\nosupersub\cf2\f3\fs22 Augmentative and \par\pard\qj \li1551\ri695\sb0\sl
-260\slmult0 \up0 \expndtw-9\charscalex97 Alternative Communication is an area o
f clinical practice that attempts \line \up0 \expndtw-9\charscalex100 to compens
ate (either temporarily or permanently) for the impairment \line \up0 \expndtw-9
\charscalex94 and disability patterns of individuals with severe expressive comm
unica-\line \up0 \expndtw-9\charscalex91 tion disorders (i.e., the severely spee
ch-language impaired)\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub
\cf2\f3\fs22 (ASHA, 1991, \par\pard\qj \li1551\ri696\sb0\sl-260\slmult0\fi0 \up
0 \expndtw-10\charscalex91 p. 10). Beukelman,Yorkston, & Dowden (1985) dened augm
entative and \line \up0 \expndtw-9\charscalex93 alternative communication\ul0\n
osupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 . . .as any
approach designed to support, \line \up0 \expndtw-7\charscalex100 enhance,
or augment the communication of individuals who are not \line \up0 \expndtw-9\ch
arscalex93 independent verbal communicators in all situations\ul0\nosupersub\cf1
1\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 (p. 3). Augmentative
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
231}{\bkmkend Pg231}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7208 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 211\par\pard\ql \li
1286\sb0\sl-258\slmult0 \par\pard\ql\li1286\ri959\sb45\sl-258\slmult0\tx1764 \up
0 \expndtw-10\charscalex94 communication is something used in addition to one\ul
0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s speech, whereas
\line \up0 \expndtw-10\charscalex90 alternative communication is used in place o
f one\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s speech.
\line \tab \up0 \expndtw-10\charscalex96 Individuals with various disabilities c
an be assisted by AAC tech-\line \up0 \expndtw-9\charscalex92 niques. Regardless
of disability, age, or background, AAC users have one \line \up0 \expndtw-10\ch
arscalex94 thing in common: they are unable to eectively communicate everything \
line \up0 \expndtw-9\charscalex94 that they want using their current modes of co
mmunication. Typically, an \line \up0 \expndtw-9\charscalex89 individual\ul0\nos
upersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s communication is expr
essed via speech, facial expressions, ges-\line \up0 \expndtw-9\charscalex93 tur
es, and writing. Many disabilities may impair one or all of these modes \line \u
p0 \expndtw-9\charscalex97 of communication. A disability may occur at any time
in a person\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s li
fe. \line \up0 \expndtw-9\charscalex92 Congenital or developmental disabilities,
which occur before, at, or around \line \up0 \expndtw-9\charscalex94 the time o
f birth, may include disorders such as cerebral palsy, develop-\line \up0 \expnd
tw-9\charscalex92 mental delays, mental retardation, Down\ul0\nosupersub\cf11\f1
2\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s syndrome, hearing impairment, \line
\up0 \expndtw-9\charscalex95 and autism. Acquired disorders are impairments that
are sustained after \line \up0 \expndtw-9\charscalex100 birth, such as hearing

impairment and mutism, and can be caused by \line \up0 \expndtw-9\charscalex91 e

vents such as traumatic brain injury, cerebrovascular accidents \up0 \exp
ndtw-10\charscalex85 (e.g., \par\pard\qj \li1286\ri961\sb1\sl-260\slmult0 \up0 \
expndtw-9\charscalex100 stroke), spinal cord injury, mutism, hearing impairment,
and laryngec-\line \up0 \expndtw-9\charscalex97 tomy. A progressive disability
is identied when an individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersu
b\cf2\f3\fs22 s abilities \line \up0 \expndtw-9\charscalex92 decline or degener
ate over time; examples include multiple sclerosis, \line \up0 \expndtw-9\
charscalex87 amyotrophic lateral sclerosis (Lou Gehrig\ul0\nosupersub\cf11\f12\f
s22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s disease), and Parkinson\ul0\nosupersub\
cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s disease. \par\pard\qj \li1286
\ri960\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex93 These disabilities
can aect one\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s a
bility to communicate in varying \line \up0 \expndtw-9\charscalex100 degrees. So
me individuals will experience minor di\u8260?culties expressing \line \up0 \exp
ndtw-10\charscalex97 themselves and may only need AAC to repair breakdowns in co
mmu-\line \up0 \expndtw-6\charscalex100 nication. Another group of individuals m
ay be left with unintelligible \line \up0 \expndtw-10\charscalex96 speech (i.e.
, speech that is not easily understood by a communication \line \up0 \expndtw-9\
charscalex98 partner); for these individuals AAC has a larger role in their tota
l com-\line \up0 \expndtw-9\charscalex94 munication interactions. Others may be
unable to speak or write and will \line \up0 \expndtw-9\charscalex100 depend on
AAC as their primary mode of communication. Some indi-\line \up0 \expndtw-9\char
scalex96 viduals may experience a temporary loss in their ability to s
peak. \line \up0 \expndtw-10\charscalex97 These include people with a tracheosto
my, those who have had long-\line \up0 \expndtw-9\charscalex95 term intubation,
those who have experienced a mental or physical \line \up0 \expndtw-9\c
harscalex98 trauma, and those who have had long-term or chronic laryngi
tis. \line \up0 \expndtw-6\charscalex100 These individuals may require short-ter
m or temporary use of AAC \line \up0 \expndtw-10\charscalex88 techniques. \par\p
ard\qj \li1286\ri960\sb1\sl-260\slmult0\fi478 \up0 \expndtw-6\charscalex100 Indi
viduals who present with minor di\u8260?culties expressing them-\line \up0 \expn
dtw-9\charscalex97 selves, specically related to low-volume and mild speech intel
ligibility \line \up0 \expndtw-10\charscalex96 issues, may benet from the use of
amplication systems and speech \line \up0 \expndtw-10\charscalex90 processors. Am
plication systems and speech processors are designed to \line \up0 \expndtw-9\cha
rscalex91 enhance an individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosup
ersub\cf2\f3\fs22 s current verbal output. Amplication systems
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz85\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
232}{\bkmkend Pg232}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2657 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 212\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\qj \li1551\sb0\sl-240\slmult0 \par\pard\qj\li1551\ri697\sb106\sl-240\slm
ult0 \up0 \expndtw-9\charscalex89 \ul0\nosupersub\cf2\f3\fs22 increase speech v
olume, whereas speech processors not only increase \up0 \expndtw-10\charsc
alex89 volume but also clarify speech. \par\pard\qj \li1551\ri696\sb4\sl-260\slm
ult0\fi478 \up0 \expndtw-7\charscalex100 Those individuals who exhibit more di\u
8260?culties expressing them\up0 \expndtw-9\charscalex95 selves verbally may req

uire alternative forms of communication in addi\up0 \expndtw-10\charscalex93 tio

n to their speech, specically AAC. \par\pard\qj \li1551\ri695\sb0\sl-260\slmult0\
fi478 \up0 \expndtw-9\charscalex100 Since its inception, the philosophy of AAC a
nd its use in clinical \line \up0 \expndtw-9\charscalex89 practice have changed
dramatically. Research and knowledge of individuals \line \up0 \expndtw-9\charsc
alex88 withdisabilities has increased, and this increase has helped to facilitat
edevel-\line \up0 \expndtw-9\charscalex89 opments in the eld of AAC.Various laws
have been enacted and legislative \line \up0 \expndtw-9\charscalex89 decisions h
ave been made to ensure that individuals with disabilities receive \line \up0 \e
xpndtw-9\charscalex93 the services (i.e., AAC evaluation and training) that they
need to facilitate \line \up0 \expndtw-9\charscalex97 independence. Legislative
decisions include, but are not limited to, the \line \up0 \expndtw-9\charscalex
93 Rehabilitation Act of 1973 (P.L. 93 -112), the Consolidated Omnibus \
line \up0 \expndtw-9\charscalex92 Budget Reconciliation Act of 1986 (P.L. 99 -50
9), the Technology-Related \line \up0 \expndtw-9\charscalex89 Assistance for Ind
ividuals with Disabilities Act of 1988 (Tech Act) (P.L. 100 -\line \up0 \expndtw
-9\charscalex91 407) and its amendment in 1994 (P.L. 103 -218), the Amer
icans with \line \up0 \expndtw-9\charscalex98 Disabilities Act (ADA) of 1990 (P
.L. 101-336), and the Individuals with \line \up0 \expndtw-9\charscalex90 Disabi
lities Education Act (IDEA) (P.L. 101- 476) (Cook and Hussey, 1995). \line \up0
\expndtw-9\charscalex91 All these legislative decisions, in addition to others,
facilitate independence \line \up0 \expndtw-10\charscalex96 and educational, med
ical, and employment support for individuals with \line \up0 \expndtw-10\charsca
lex90 disabilities. \par\pard\qj \li1551\ri695\sb3\sl-257\slmult0\fi478 \up0 \ex
pndtw-10\charscalex96 Over the years, many changes within the eld of AAC have bee
n \line \up0 \expndtw-10\charscalex92 seen (e.g., the acceptance of AAC in commu
nities, the types and number \line \up0 \expndtw-10\charscalex92 of available co
mmunication systems, the type of vocabulary used in AAC \line \up0 \expndtw-10\c
harscalex93 systems, and the number of funding agencies). AAC is a growing eld in
\line \up0 \expndtw-10\charscalex95 which new communication devices and access
methods are constantly \line \up0 \expndtw-9\charscalex93 being introduced. Tec
hnologic advancements have enabled electronic \line \up0 \expndtw-10\charsca
lex91 communication systems to become smaller and include various advanced \line
\up0 \expndtw-9\charscalex97 features. Continual growth in the eld of AAC provid
es individuals with \line \up0 \expndtw-10\charscalex97 a larger selection of co
mmunication systems to nd the one that most \line \up0 \expndtw-10\charscalex93 o
ptimally meets their needs. \par\pard\qj \li1551\ri696\sb1\sl-260\slmult0\fi478
\up0 \expndtw-9\charscalex100 AAC is used to improve language skills. Language s
kills can be \line \up0 \expndtw-10\charscalex93 broken down into three segments
: receptive, expressive, and pragmatic. \line \up0 \expndtw-10\charscalex94 Rece
ptive language is the comprehension of language (i.e., commands \line \up0 \expn
dtw-9\charscalex90 and language concepts [e.g., big versus small]). Expressive l
anguage is the \line \up0 \expndtw-10\charscalex93 speech sounds and grammatical
rules of language. Pragmatic language \line \up0 \expndtw-9\charscalex95 is the
use of language (i.e., what our message is accomplishing, [e.g., a \line \up0 \
expndtw-10\charscalex95 greeting]).
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz85\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
233}{\bkmkend Pg233}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7208 \up0 \expndtw-8\chars

calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t

ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 213\par\pard\qj \li
1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri960\sb42\sl-260\slmult0\fi478 \up0
\expndtw-10\charscalex92 AAC symbols may be used in various ways to facilitate
the learning \line \up0 \expndtw-9\charscalex94 of language concepts and und
erstanding of the spoken word. V|sual \line \up0 \expndtw-5\charscalex100 cue
s the pairing of an AAC photograph or symbol with the verbal \line \up0 \expnd
tw-10\charscalex96 word enhance the learning of a specic word, concept, or comm
and. \line \up0 \expndtw-9\charscalex100 Therefore vocabulary growth and reading
can be aided by the use of \line \up0 \expndtw-10\charscalex92 AAC. Transition
boards or schedules use AAC photographs and symbols \line \up0 \expndtw-9\charsc
alex94 as visual representations of the events or activities in one\ul0\nos
upersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s day. This \line \up0
\expndtw-8\charscalex100 enables an individual to anticipate what will happen in
his or her day \line \up0 \expndtw-10\charscalex92 on a more concrete level. \p
ar\pard\qj \li1286\ri961\sb0\sl-264\slmult0\fi478 \up0 \expndtw-5\charscalex100
The goal of AAC is communication. Using AAC, an individual \up0 \expndtw-9\chars
calex95 can gain attention; make choices; request; protest; comment; greet; ask
\up0 \expndtw-9\charscalex95 and answer questions; request clarication; gain info
rmation; and regu\up0 \expndtw-9\charscalex95 late a conversation, activity, or
his or her environment. These pragmatic \up0 \expndtw-10\charscalex92 functions
can be expressed using simple, concrete AAC systems or more \up0 \expndtw-10\cha
rscalex88 abstract, complex systems. \par\pard\ql \li2591\sb0\sl-276\slmult0 \pa
r\pard\ql\li2591\sb0\sl-276\slmult0 \par\pard\ql\li2591\sb92\sl-276\slmult0 \up0
\expndtw0\charscalex100 \ul0\nosupersub\cf7\f8\fs24 WHAT AFFECTS THE TYPE OF \p
ar\pard\qj \li1933\ri1651\sb1\sl-280\slmult0\tx2717 \up0 \expndtw0\charscalex105
AN AUGMENTATIVE AND ALTERNATIVE \line\tab \up0 \expndtw0\charscalex100 COMMUNIC
ATION SYSTEM? \par\pard\qj \li1286\ri961\sb257\sl-260\slmult0\fi478 \up0 \expndt
w-10\charscalex94 \ul0\nosupersub\cf2\f3\fs22 Language and cognitive skills
and visual, auditory, and motor/ \line \up0 \expndtw-10\charscalex96 position
ing status play an important role in the design and use of AAC \line \up0 \expnd
tw-10\charscalex83 systems. \par\pard\ql \li2137\sb0\sl-207\slmult0 \par\pard\ql
\li2137\sb0\sl-207\slmult0 \par\pard\ql\li2137\sb150\sl-207\slmult0 \up0 \expndt
w0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 R\ul0\nosupersub\cf31\f32\fs17 ECEP
TIVE\ul0\nosupersub\cf7\f8\fs24 L\ul0\nosupersub\cf31\f32\fs17 ANGUAGE\ul0\nosu
persub\cf7\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 KILLS AND\ul0\nosupersub\cf7\
f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 OGNITION \par\pard\qj \li1286\sb0\sl-262
\slmult0 \par\pard\qj\li1286\ri959\sb6\sl-262\slmult0\fi478 \up0 \expndtw-10\cha
rscalex94 \ul0\nosupersub\cf2\f3\fs22 Cognitive and receptive language skills of
the individual determine \line \up0 \expndtw-9\charscalex100 the complexity of
the AAC system. Basic cognitive and receptive lan-\line \up0 \expndtw-10\charsca
lex94 guage skills are needed to use the simplest forms of AAC. They include \li
ne \up0 \expndtw-9\charscalex100 object permanence, cause and eect skills, the f
ollowing of one-step \line \up0 \expndtw-10\charscalex93 commands, comprehension
of simple language concepts, eye contact or \line \up0 \expndtw-10\charscalex96
awareness of objects, identication of objects, motivation to communi-\line \up0
\expndtw-10\charscalex94 cate, and communicative intent (purposeful communicatio
n). More com-\line \up0 \expndtw-10\charscalex96 plex AAC systems require advanc
ed receptive language and cognitive \line \up0 \expndtw-10\charscalex97 skills.
These skills include: the following of multistep commands; the
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz94\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s

p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}

}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
234}{\bkmkend Pg234}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2653 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 214\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\qj \li1551\sb0\sl-262\slmult0 \par\pard\qj\li1551\ri696\sb66\sl-262\slmu
lt0 \up0 \expndtw-7\charscalex100 \ul0\nosupersub\cf2\f3\fs22 identication of pho
tographs, picture symbols, letters, or the written \up0 \expndtw-9\charscalex97
word; literacy skills; sequencing skills; and the comprehension of more \up0 \ex
pndtw-8\charscalex100 abstract language concepts. If an individual does not exhi
bit the skills \up0 \expndtw-10\charscalex94 needed for a basic AAC system, then
he or she should be trained in the \up0 \expndtw-9\charscalex95 necessary prere
quisite skills. When an individual has these skills and is \up0 \expndtw-9\chars
calex95 using a basic AAC system, training should continue to develop the skills
\up0 \expndtw-10\charscalex90 necessary for a more advanced AAC system that pro
vides access to more \up0 \expndtw-10\charscalex94 vocabulary. Receptive languag
e skills help to determine which symbols \up0 \expndtw-10\charscalex93 are most
appropriate for the AAC system. \par\pard\ql \li4107\sb0\sl-253\slmult0 \par\par
d\ql\li4107\sb253\sl-253\slmult0 \up0 \expndtw-4\charscalex100 Symbol Set \par\p
ard\qj \li1551\ri696\sb117\sl-266\slmult0\fi478 \up0 \expndtw-10\charscalex90 Th
e vocabulary items within an AAC system are called a symbol set. \line \up0 \exp
ndtw-9\charscalex100 Vocabulary items vary in content and complexity. The symbol
set can \line \up0 \expndtw-9\charscalex95 contain vocabulary items that ran
ge from very concrete (i.e., use of \line \up0 \expndtw-10\charscalex95 obje
cts) to abstract \up0 \expndtw-10\charscalex95 (i.e., use of words). Development
ally, language is \par\pard\qj \li1551\ri694\sb0\sl-260\slmult0 \up0 \expndtw-9
\charscalex94 learned through objects rst and then through more abstract represen
ta-\line \up0 \expndtw-9\charscalex97 tions; such as photographs, line draw
ings or symbols, and words \line \up0 \expndtw-10\charscalex87 (Table \up0 \
expndtw-10\charscalex88 9.1) Letter boards \up0 \expndtw-10\charscalex93 (comm
unication boards that resemble key-\par\pard\qj \li1551\ri695\sb17\sl-263\sl
mult0 \up0 \expndtw-9\charscalex100 boards) and word boards represent the most a
bstract symbol set. An \up0 \expndtw-9\charscalex96 individual\ul0\nosupersub\cf
11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s development within the symbol s
et hierarchy will determine \up0 \expndtw-10\charscalex96 the symbol set used on
his or her communication system. The specic \up0 \expndtw-9\charscalex94 symbol
set comprises one symbol type (i.e., objects) or a combination of \up0 \expndtw10\charscalex94 symbol types (i.e., objects and photographs or photographs and p
icture \up0 \expndtw-10\charscalex93 symbols).When a symbol set contains multipl
e symbol types, the set can \up0 \expndtw-10\charscalex94 then be called a exible
symbol set. \par\pard\qj \li1551\ri694\sb0\sl-264\slmult0\fi478 \up0 \expndtw-1
0\charscalex95 Many commercial picture symbol libraries are available, including
\line \up0 \expndtw-10\charscalex94 Picture Communication Symbols (Mayer-Johns
on, Inc., Solana Beach, \line \up0 \expndtw-10\charscalex94 CA), DynaSyms (DynaV
ox Systems LLC, a division of Sunrise Medical, \line \up0 \expndtw-9\charscalex9
2 Inc., Pittsburgh, PA), and Minspeak\ul0\super\cf34\f35\fs23 7\ul0\nosupersub\c
f2\f3\fs22 (Baker, 1982) to name a few. These \line \up0 \expndtw-9\charscalex
93 libraries vary in the level of symbol abstractness. Some symbol sets con-\lin
e \up0 \expndtw-9\charscalex100 tain symbols that depict only one vocabulary ite
m per symbol (i.e., a \line \up0 \expndtw-9\charscalex92 picture symbol of an a
pple expresses\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f
3\fs22 apple\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\f
s22 ). Other symbol sets contain \line \up0 \expndtw-9\charscalex92 symbols that
have multiple meanings (i.e., picture symbol of an apple can \line \up0 \expndt
w-9\charscalex92 represent the words\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216
?\ul0\nosupersub\cf2\f3\fs22 apple\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosu
persub\cf2\f3\fs22 ,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub
\cf2\f3\fs22 fruit,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\c
f2\f3\fs22 or\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3

\fs22 eat\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22

) depending on its combination \line \up0 \expndtw-9\charscalex94 with other sy
mbols (called semantic compaction [e.g., Unity]) (Badman \line \up0 \expndtw10\charscalex94 et al., \up0 \expndtw-10\charscalex94 1995). The library cho
sen should reect the user\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub
\cf2\f3\fs22 s cognitive
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz103\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
235}{\bkmkend Pg235}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7210 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 215\par\pard\li2473
\sb0\sl-207\slmult0\par\pard\li2473\sb0\sl-207\slmult0\par\pard\li2473\sb0\sl-20
7\slmult0\par\pard\li2473\sb0\sl-207\slmult0\par\pard\li2473\sb0\sl-207\slmult0\
par\pard\li2473\sb0\sl-207\slmult0\par\pard\li2473\sb0\sl-207\slmult0\par\pard\l
i2473\sb0\sl-207\slmult0\par\pard\li2473\sb0\sl-207\slmult0\par\pard\li2473\sb0\
sl-207\slmult0\par\pard\li2473\sb150\sl-207\slmult0\fi1590 \up0 \expndtw-3\chars
calex100 \ul0\nosupersub\cf5\f6\fs18 Table 9.1\par\pard\li2473\sb72\sl-207\slmul
t0\fi0 \up0 \expndtw-3\charscalex100 Hierarchy of Symbol Set (from Most Concrete
to\par\pard\li2362\sb12\sl-207\slmult0\fi1452 \up0 \expndtw-5\charscalex100 Mos
t Abstract)\par\pard\li2362\sb75\sl-207\slmult0\fi0 \up0 \expndtw-5\charscalex10
0 Object level\par\pard\li2362\sb13\sl-207\slmult0\fi180 \up0 \expndtw-5\charsca
lex100 Exact object\par\pard\qj \li2542\ri2069\sb0\sl-220\slmult0 \up0 \expndtw8\charscalex94 Partial object (e.g., label on bottle of bubble solution to \up0
\expndtw-8\charscalex89 represent bubbles) \par\pard\qj \li2542\ri2226\sb0\sl-22
0\slmult0 \up0 \expndtw-8\charscalex91 Associated object (e.g., spoon to represe
nt lunchtime) \up0 \expndtw-8\charscalex92 Miniature object \par\pard\ql \li2362
\sb120\sl-207\slmult0 \up0 \expndtw-2\charscalex100 Photographic level \par\pard
\qj \li2542\ri2128\sb3\sl-220\slmult0 \up0 \expndtw-8\charscalex96 Color photogr
aph of exact object with no background \up0 \expndtw-8\charscalex95 Black and wh
ite photograph of exact object with no \line \up0 \expndtw-8\charscalex96 backgr
ound \par\pard\ql \li2542\sb11\sl-207\slmult0 \up0 \expndtw-8\charscalex100 Colo
r photograph with background \par\pard\ql \li2542\sb13\sl-207\slmult0 \up0 \expn
dtw-8\charscalex96 Black and white photograph with background \par\pard\ql \li23
62\sb133\sl-207\slmult0 \up0 \expndtw-2\charscalex100 Picture symbol level \par\
pard\ql \li2542\sb13\sl-207\slmult0 \up0 \expndtw-8\charscalex100 Color line dra
wing or picture symbol \par\pard\ql \li2542\sb13\sl-207\slmult0 \up0 \expndtw-8\
charscalex96 Black and white line drawing or picture symbol \par\pard\ql \li2362
\sb133\sl-207\slmult0 \up0 \expndtw-4\charscalex100 Word level \par\pard\qj \li2
542\ri3656\sb19\sl-200\slmult0 \up0 \expndtw-8\charscalex91 Whole word, phrase,
or sentence \up0 \expndtw-8\charscalex92 Spelling
{\shp {\*\shpinst\shpleft2362\shptop4150\shpright6427\shpbottom4170\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz6\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 4065}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(4065,0);(4065,20);(0,20)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s

p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s

p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft2362\shptop8561\shpright6427\shpbottom8582\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz8\shplid1
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 4065}}{\sp{\sn geoBottom}{\sv 21}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(4065,0);(4065,21);(0,21)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz110\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
236}{\bkmkend Pg236}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2653 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 216\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\qj \li1551\sb0\sl-240\slmult0 \par\pard\qj\li1551\ri697\sb106\sl-240\slm
ult0 \up0 \expndtw-9\charscalex100 \ul0\nosupersub\cf2\f3\fs22 developmental lev
el. Symbol sets can include one symbol library or a \up0 \expndtw-9\charscalex10
0 combination of two or more libraries. \par\pard\qj \li1551\ri694\sb4\sl-260\sl
mult0\fi478 \up0 \expndtw-10\charscalex94 A picture symbol may be used to repres
ent a single word, phrase, \up0 \expndtw-10\charscalex92 sentence, or extended p
aragraph. When symbols represent single words \up0 \expndtw-10\charscalex94 or p
hrases, they may be combined or strung together to construct novel \up0 \expndtw
-9\charscalex96 sentences (i.e.,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul
0\nosupersub\cf2\f3\fs22 I\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosup
ersub\cf2\f3\fs22 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\c
f2\f3\fs22 want\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f
3\fs22 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22
to go\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 \ul
0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 home\ul0\n
osupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 produces the
gramma\up0 \expndtw-9\charscalex96 tically correct sentence\ul0\nosupersub\cf11\
f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 I want to go home.\ul0\nosup
ersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 ). Communication s
ystems \up0 \expndtw-9\charscalex89 can also contain single letters, words, phra
ses, or sentences. Letters can be \up0 \expndtw-10\charscalex89 used to spell wo
rds to construct novel utterances. \par\pard\qj \li1551\ri694\sb0\sl-260\slmult0
\fi478 \up0 \expndtw-10\charscalex94 Morse code (Vanderheiden & Lloyd, 1986
) is an international \line \up0 \expndtw-10\charscalex92 system that uses da
shes and dots to spell out words and sentences. The \line \up0 \expndtw-10\chars
calex92 dashes and dots are combined in a predetermined way to produce letters \
line \up0 \expndtw-9\charscalex100 of the alphabet, punctuation, and numbers. Br
aille (Scholl, 1986) is a \line \up0 \expndtw-9\charscalex93 tactile symbol sys
tem that uses six embossed dots to represent letters of \line \up0 \expndtw-9\ch

arscalex93 the alphabet, parts of words, and entire words. The way that the dots
are \line \up0 \expndtw-9\charscalex97 arranged determines their meaning. Brail
le is typically used by individ-\line \up0 \expndtw-8\charscalex100 uals who are
visually impaired or dual sensory impaired. Both Morse \line \up0 \expndtw-10\c
harscalex92 code and Braille can be used on communication systems. \par\pard\qj
\li1551\ri696\sb3\sl-257\slmult0\fi478 \up0 \expndtw-10\charscalex91 AAC symbols
or photographs, Braille, and Morse code may be used \line \up0 \expndtw-9\chars
calex93 in various ways to facilitate the learning of language concepts and unde
r-\line \up0 \expndtw-10\charscalex93 standing of the spoken word. V|sual cues w
ith the verbal word enhances \line \up0 \expndtw-9\charscalex93 the learning of
a specic word, concept, or command. In this way, vocab-\line \up0 \expndtw-9\char
scalex100 ulary growth and reading can be aided by the use of AAC. Transition \l
ine \up0 \expndtw-9\charscalex93 boards or schedules may use AAC photograph
s or symbols, Braille, \line \up0 \expndtw-9\charscalex93 Morse code, or word
s as visual representations of the events or activities \line \up0 \expndtw-9\ch
arscalex94 in one\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs2
2 s day. This enables an individual to anticipate what will happen in \line \up0
\expndtw-10\charscalex92 his or her day in a more concrete way than with spoken
words alone. \par\pard\qj \li1551\ri694\sb1\sl-260\slmult0\fi478 \up0 \expndtw10\charscalex94 In a communication system, the number of cells (that may contain
\line \up0 \expndtw-10\charscalex96 symbols, words, or letters) with the spaces
between them is called the \line \up0 \expndtw-10\charscalex93 symbol grid. The
amount of symbols placed on a communication system \line \up0 \expndtw-9\charsc
alex92 depends on the grid size.W|thin a specic area, as the number of symbols \l
ine \up0 \expndtw-9\charscalex90 increase, the size of those symbols decreases (
i.e., given a 3 inch by 3 inch \line \up0 \expndtw-10\charscalex94 symbol grid o
ne can have one 3 inch by 3 inch symbol or nine 1 inch by \line \up0 \expndtw-10
\charscalex93 1 inch symbols). In some communication systems the size of the sym
bol \line \up0 \expndtw-9\charscalex94 grid is limited (only a few grids are ava
ilable for that system), and others \line \up0 \expndtw-8\charscalex100 allow fo
r varied symbol grids (multiple numbers of possible grids are \line \up0 \expndt
w-9\charscalex100 available) or adjustable symbol grids (can create any number
of grid \line \up0 \expndtw-10\charscalex84 designs).
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz120\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
237}{\bkmkend Pg237}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7217 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 217\par\pard\ql \li
3708\sb0\sl-207\slmult0 \par\pard\ql\li3708\sb139\sl-207\slmult0 \up0 \expndtw0\
charscalex103 \ul0\nosupersub\cf7\f8\fs24 V\ul0\nosupersub\cf31\f32\fs17 ISION\u
l0\nosupersub\cf7\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 KILLS \par\pard\qj \li
1286\ri959\sb246\sl-265\slmult0\fi478 \up0 \expndtw-10\charscalex97 \ul0\nosuper
sub\cf2\f3\fs22 An individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersu
b\cf2\f3\fs22 s visual skills (visual xation, tracking, acuity, and \line \up0
\expndtw-10\charscalex96 perceptual skills) will determine how his or her commun
ication system \line \up0 \expndtw-8\charscalex100 will look. V|sual skills dete
rmine symbol size, the number of symbols \line \up0 \expndtw-10\charscalex92 use
d, the symbol grid, and symbol set placement. Although some people \line \up0 \e
xpndtw-8\charscalex100 can identify an individual 1 inch by 1 inch symbol

, they may have \line \up0 \expndtw-7\charscalex100 di\u8260?culty discriminatin

g that symbol when it is surrounded by 20 other \line \up0 \expndtw-9\charscalex
100 symbols. This visual overstimulation can easily be rectied by either \line \
up0 \expndtw-9\charscalex95 decreasing the total number of symbols on the grid o
r by increasing the \line \up0 \expndtw-10\charscalex91 size of the symbols. \pa
r\pard\qj \li1286\ri960\sb0\sl-263\slmult0\fi478 \up0 \expndtw-7\charscalex100 I
t is important to be aware of any and all visual decits an indi-\line \up0 \expnd
tw-9\charscalex95 vidual has. If an individual has a left eld cut, all visual sti
muli should be \line \up0 \expndtw-9\charscalex97 presented on his or her right
side.When an individual is blind or legally \line \up0 \expndtw-9\charscalex97 b
lind or has impaired vision, tactile symbol sets (i.e., symbols that use \line \
up0 \expndtw-6\charscalex100 texture) or auditory prompts (i.e., the label of t
he vocabulary item is \line \up0 \expndtw-10\charscalex95 spoken before selectio
n) can be used to aid in symbol recognition. The \line \up0 \expndtw-9\charscale
x96 use of colors may also aid visual recognition (e.g., the use of black
\line \up0 \expndtw-9\charscalex95 symbols on a yellow background). If an indiv
idual has visual processing \line \up0 \expndtw-9\charscalex97 di\u8260?culties,
these di\u8260?culties need to be identied to make the appropriate \line \up0 \e
xpndtw-10\charscalex93 accommodations to his or her AAC system. Some AAC users w
ith visual \line \up0 \expndtw-5\charscalex100 processing di\u8260?culties may b
enet from the use of auditory prompts \line \up0 \expndtw-10\charscalex90 because
they cue the user as to what the vocabulary items are. \par\pard\ql \li3545\sb0
\sl-207\slmult0 \par\pard\ql\li3545\sb0\sl-207\slmult0 \par\pard\ql\li3545\sb0\s
l-207\slmult0 \par\pard\ql\li3545\sb60\sl-207\slmult0 \up0 \expndtw0\charscalex1
04 \ul0\nosupersub\cf7\f8\fs24 A\ul0\nosupersub\cf31\f32\fs17 UDITORY\ul0\nosupe
rsub\cf7\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 KILLS \par\pard\qj \li1286\sb0\
sl-264\slmult0 \par\pard\qj\li1286\ri960\sb2\sl-264\slmult0\fi478 \up0 \expndtw10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 An individual\ul0\nosupersub\cf11\f1
2\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s auditory skills (i.e., auditory acui
ty and processing) \line \up0 \expndtw-9\charscalex94 are important in the desig
n of and training to use an AAC system. These \line \up0 \expndtw-9\charscalex95
skills will determine how information is presented (i.e., whether auditory \lin
e \up0 \expndtw-9\charscalex94 or visual input is used and to what degree). If a
n individual has a hearing \line \up0 \expndtw-9\charscalex95 impairment, perhap
s an increase in volume is all that is needed to facil-\line \up0 \expndtw-7\cha
rscalex100 itate comprehension of the vocabulary items. If an individual has no
\line \up0 \expndtw-9\charscalex97 functional hearing, then sign language or vis
ual cues will be needed to \line \up0 \expndtw-9\charscalex95 aid in the learnin
g of his or her communication system. Hypersensitivity \line \up0 \expndtw-10\ch
arscalex96 and auditory processing di\u8260?culties need to be identied and addre
ssed \line \up0 \expndtw-10\charscalex93 when one designs and trains an individu
al to use an AAC system.
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz94\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
238}{\bkmkend Pg238}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2654 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 218\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\qj \li1551\sb0\sl-262\slmult0 \par\pard\qj\li1551\ri695\sb66\sl-262\slmu
lt0\fi478 \up0 \expndtw-10\charscalex93 \ul0\nosupersub\cf2\f3\fs22 Electronic A

AC systems use various voice output types. It is impor-\line \up0 \expndtw-10\ch

arscalex90 tant to make sure that the AAC user can hear and comprehend the speec
h \line \up0 \expndtw-8\charscalex100 produced by his or her communication syste
m. If an individual has a \line \up0 \expndtw-10\charscalex95 hearing impairment
, the external speakers may be needed to aid in the \line \up0 \expndtw-6\charsc
alex100 comprehension of his or her selection. If the user has no functional \li
ne \up0 \expndtw-9\charscalex100 hearing, then the AAC system may need to have v
isual output (i.e., a \line \up0 \expndtw-9\charscalex91 typed message) or tacti
le feedback so the user knows he or she has made \line \up0 \expndtw-9\charscale
x94 a selection.When one works with an individual who has a hearing loss or \lin
e \up0 \expndtw-8\charscalex100 is deaf in one ear, it is important to make sure
that the speaker of the \line \up0 \expndtw-10\charscalex93 communication syste
m is near his or her good ear. \par\pard\ql \li3450\sb0\sl-207\slmult0 \par\pard
\ql\li3450\sb0\sl-207\slmult0 \par\pard\ql\li3450\sb0\sl-207\slmult0 \par\pard\q
l\li3450\sb63\sl-207\slmult0 \up0 \expndtw0\charscalex101 \ul0\nosupersub\cf7\f8
\fs24 P\ul0\nosupersub\cf31\f32\fs17 HYSICAL\ul0\nosupersub\cf7\f8\fs24 /M\ul0\n
osupersub\cf31\f32\fs17 OTOR\ul0\nosupersub\cf7\f8\fs24 I\ul0\nosupersub\cf31\f
32\fs17 SSUES \par\pard\qj \li1551\sb0\sl-262\slmult0 \par\pard\qj\li1551\ri694\
sb6\sl-262\slmult0\fi478 \up0 \expndtw-10\charscalex97 \ul0\nosupersub\cf2\f3\fs
22 An individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22
s physical status and motor skills play an important \line \up0 \expndtw-10\cha
rscalex95 role in the type and design of an AAC system. Whether an individual is
\line \up0 \expndtw-8\charscalex100 ambulatory or uses a wheelchair will aect th
e size and weight of the \line \up0 \expndtw-6\charscalex100 communication syste
m. An ambulatory individual will need a light-\line \up0 \expndtw-7\charscalex1
00 weight and portable system to allow him or her to carry and use the \line \up
0 \expndtw-10\charscalex95 AAC system in all environments. Because communication
systems can \line \up0 \expndtw-9\charscalex97 be physically attached to wheelc
hairs, walkers, strollers, or canes, the \line \up0 \expndtw-9\charscalex98 weig
ht and portability of the system is less of an issue if the individual \line \up
0 \expndtw-10\charscalex94 is not ambulatory. \par\pard\qj \li1551\ri695\sb0\sl264\slmult0\fi478 \up0 \expndtw-10\charscalex94 Seating and positioning are impe
rative because all mobility comes \line \up0 \expndtw-9\charscalex89 from a stab
le base. The reason it is easier to eat when sitting as opposed to \line \up0 \e
xpndtw-10\charscalex93 standing or standing on one foot is because one has a mor
e stable base \line \up0 \expndtw-9\charscalex92 when sitting. A stable base can
usually be achieved by 90 -degree angles \line \up0 \expndtw-9\charscalex95 at
the hips and knees. This base will allow for more neutral muscle tone \line \up0
\expndtw-6\charscalex100 and will facilitate optimal range of movement in all l
imbs, the trunk, \line \up0 \expndtw-9\charscalex93 and the head. To achieve a s
table base, individuals with varying degrees \line \up0 \expndtw-10\charscalex96
of muscle tone will have dierent positioning needs.When an individual \line \up0
\expndtw-10\charscalex93 demonstrates hyperextension patterns, it may be benecia
l to place him \line \up0 \expndtw-9\charscalex92 or her in exion (i.e., less tha
n 90 -degree angle). If an individual presents \line \up0 \expndtw-9\charscalex1
00 with a limited range of motion, then a smaller communication system \line \up
0 \expndtw-10\charscalex93 would be necessary to accommodate his or her range. A
n individual with \line \up0 \expndtw-7\charscalex100 a larger range of motion w
ould be able to access items on a larger \line \up0 \expndtw-10\charscalex93 c
ommunication system.
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz96\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s

p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}

}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
239}{\bkmkend Pg239}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7213 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 219\par\pard\qj \li
1286\sb0\sl-260\slmult0 \par\pard\qj\li1286\ri960\sb42\sl-260\slmult0\fi478 \up0
\expndtw-8\charscalex100 A controlled, volitional, and reliable movement of a b
ody part is \line \up0 \expndtw-9\charscalex91 essential for accessing vocabular
y items on a communication system. The \line \up0 \expndtw-10\charscalex96 movem
ent can be as typical as a nger touch or as atypical as an eye \line \up0 \expndt
w-7\charscalex100 blink. This movement must be able to be performed with accura
cy, \line \up0 \expndtw-9\charscalex92 relative ease, and the least amount of fa
tigue as possible. This will ensure \line \up0 \expndtw-7\charscalex100 that vo
cabulary selections will be done in a timely manner and \line \up0 \exp
ndtw-9\charscalex97 that the individual will be able to communicate thro
ughout his or \line \up0 \expndtw-10\charscalex87 her day. \par\pard\ql \li354
2\sb0\sl-253\slmult0 \par\pard\ql\li3542\sb0\sl-253\slmult0 \par\pard\ql\li3542\
sb120\sl-253\slmult0 \up0 \expndtw-10\charscalex94 Access Techniques \par\pard\q
j \li1286\ri959\sb122\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex88 There a
re two ways to access a communication system. These access \up0 \expndtw-10\char
scalex89 techniques are direct selection and indirect selection or scanning. \pa
r\pard\ql \li1764\sb0\sl-253\slmult0 \par\pard\ql\li1764\sb0\sl-253\slmult0 \par
\pard\ql\li1764\sb140\sl-253\slmult0 \up0 \expndtw-10\charscalex92 Direct Select
ion \par\pard\qj \li1286\ri959\sb121\sl-261\slmult0\fi478 \up0 \expndtw-10\chars
calex93 Direct selection is an independent, one-to-one correspondence \lin
e \up0 \expndtw-10\charscalex96 between a person\ul0\nosupersub\cf11\f12\fs22 \u
8217?\ul0\nosupersub\cf2\f3\fs22 s body and the communication system. A body par
t \line \up0 \expndtw-7\charscalex100 can physically touch the system or can hol
d something that touches \line \up0 \expndtw-10\charscalex95 vocabulary items on
the communication system. Some of the ways the \line \up0 \expndtw-10\charscale
x97 individual can directly access a vocabulary item are by using a nger, \line \
up0 \expndtw-9\charscalex95 thumb, st, open hand, elbow, foot, toe, or chin. The
individual can also \line \up0 \expndtw-9\charscalex93 use a pointer that is att
ached to or held by a nger, hand, mouth, or head \line \up0 \expndtw-10\charscale
x95 to directly select items on a communication system. Keyguards may be \line \
up0 \expndtw-9\charscalex95 used to facilitate an increase in accurate accessing
when a body part or \line \up0 \expndtw-7\charscalex100 pointer is used by isol
ating vocabulary items on the communication \line \up0 \expndtw-10\charscalex92
system. Use of a keyguard is warranted when an individual demonstrates \line \up
0 \expndtw-9\charscalex94 di\u8260?culty accessing one vocabulary item at a time
. Keyguards are typically \line \up0 \expndtw-9\charscalex95 made of plastic, wh
ich contains cut-out shapes that conform to the sym-\line \up0 \expndtw-10\chars
calex93 bols on the AAC system. They are commercially available, can be made \li
ne \up0 \expndtw-9\charscalex100 to order from certain manufacturers, or can be
made by support sta. \line \up0 \expndtw-9\charscalex94 Direct selection can also
be achieved by the use of indicators. Indicators \line \up0 \expndtw-9\charscal
ex96 are light pointers, laser pointers, infrared beams, and optical indicators.
\line \up0 \expndtw-9\charscalex92 An emulated mouse (i.e., any device that sub
stitutes for and performs the \line \up0 \expndtw-9\charscalex91 actions of a st
andard mouse) or joystick can also be used to directly select \line \up0 \expndt
w-10\charscalex91 items on a communication device. Adaptations can be made to jo
ysticks
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}

}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
240}{\bkmkend Pg240}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2663 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 220\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\qj \li1551\sb0\sl-250\slmult0 \par\pard\qj\li1551\ri695\sb88\sl-250\slmu
lt0 \up0 \expndtw-9\charscalex94 \ul0\nosupersub\cf2\f3\fs22 to accommodate for
limited physical abilities (i.e., enlarging the diameter \up0 \expndtw-9\charsca
lex98 of the joystick to facilitate better control for an individual who present
s \up0 \expndtw-10\charscalex92 with a loose grasp). \par\pard\ql \li2030\sb0\sl
-253\slmult0 \par\pard\ql\li2030\sb155\sl-253\slmult0 \up0 \expndtw-10\charscale
x91 Indirect Selection or Scanning \par\pard\qj \li1551\ri695\sb122\sl-260\slmul
t0\fi478 \up0 \expndtw-7\charscalex100 Indirect selection or scanning is a depen
dent, nondirect way of \up0 \expndtw-10\charscalex94 accessing items on a co
mmunication system. Vocabulary items are \up0 \expndtw-8\charscalex100 presen
ted to the AAC user, and a selection is made when he or she \up0 \expndtw-10\cha
rscalex93 makes a predetermined response or movement. Any nonelectronic com\up0
\expndtw-10\charscalex93 munication system may be manually scanned; for example,
the commu\up0 \expndtw-9\charscalex93 nication partner points to and says each
item and the AAC user indicates \up0 \expndtw-10\charscalex90 a selection using
a head nod. \par\pard\qj \li1551\ri694\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10
\charscalex93 Many electronic communication devices contain scanning as a
\line \up0 \expndtw-10\charscalex97 selection technique. As the vocabulary item
s are being scanned they \line \up0 \expndtw-5\charscalex100 may be visually hi
ghlighted (e.g., with lights or color) or auditorally \line \up0 \expndtw-10\ch
arscalex96 highlighted (e.g., with beeps or verbal cues). The AAC user makes his
\line \up0 \expndtw-9\charscalex96 or her selection by accessing a switch, whic
h in turn activates the com-\line \up0 \expndtw-10\charscalex94 munication devic
e. We use switches in our everyday lives; for example, \line \up0 \expndtw-9\cha
rscalex97 when we push a light switch it activates or turns on the light. There
are \line \up0 \expndtw-10\charscalex96 various switches that can be accessed by
many dierent body parts. A \line \up0 \expndtw-7\charscalex100 controlled voliti
onal movement of a body part is needed to access a \line \up0 \expndtw-9\charsca
lex95 switch. The identied body part is called the switch site. The movement \lin
e \up0 \expndtw-9\charscalex95 of that body part is what is going to activate th
e switch. Once the switch \line \up0 \expndtw-10\charscalex93 site and body part
movement have been identied, then a switch can be \line \up0 \expndtw-9\charscal
ex90 matched to them. Switches come in all sizes, shapes, and colors to accom-\l
ine \up0 \expndtw-9\charscalex93 modate dierent switch sites. Switches can be act
ivated by various meth-\line \up0 \expndtw-9\charscalex92 ods, for example, touc
h, release, breath, squeeze, and tilt or movement of \line \up0 \expndtw-9\chars
calex91 the switch. Switches also accommodate dierent degrees of pressure (e.g.,
\line \up0 \expndtw-9\charscalex93 a foot stomp or a slight nger touch). In reali
ty, once a reliable switch site \line \up0 \expndtw-10\charscalex94 and body par
t movement have been identied, a switch can be found or \line \up0 \expndtw-10\ch
arscalex95 adapted for it. \par\pard\qj \li1551\ri694\sb1\sl-260\slmult0\fi478 \
up0 \expndtw-10\charscalex92 Vocabulary items can be scanned in many dierent patt
erns. Linear \line \up0 \expndtw-8\charscalex100 scanning is the scanning of eac
h item consecutively from left to right. \line \up0 \expndtw-10\charscalex96 Cir
cular scanning is clockwise scanning of items. Row and column \line \up0 \
expndtw-10\charscalex95 scanning is consecutive scanning of rows from top to bot
tom and, once \line \up0 \expndtw-9\charscalex98 a row is selected, scanning of
each column within that row from left to \line \up0 \expndtw-10\charscalex98 rig
ht. Column and row scanning is consecutive scanning of columns
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz89\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
241}{\bkmkend Pg241}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7197 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 221\par\pard\qj \li
1286\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0\fi0 \up0 \
expndtw-9\charscalex97 from left to right and, once a column is selected, scanni
ng of each row \line \up0 \expndtw-10\charscalex96 within that column from top t
o bottom. Quadrant scanning is clockwise \line \up0 \expndtw-9\charscalex95 scan
ning of the entire display in four quadrants, and, once a quadrant is \line \up0
\expndtw-10\charscalex93 selected, scanning of items row by row and then column
by column. Top \line \up0 \expndtw-8\charscalex100 and bottom scanning is scann
ing of the top and bottom halves of the \line \up0 \expndtw-10\charscalex96 disp
lay and then scanning of items row by row and column by column. \line \up0 \expn
dtw-7\charscalex100 Left and right scanning is scanning of the left and right ha
lves of the \line \up0 \expndtw-10\charscalex96 display and then scanning of ite
ms row by row and column by column. \line \up0 \expndtw-8\charscalex100 Left, ce
nter, or right scanning is scanning of the left, center, and right \line \up0 \e
xpndtw-9\charscalex94 quadrants of the display rst and then scanning of items row
by row and \line \up0 \expndtw-7\charscalex100 column by column. Group scanning
is scanning of set groups in the \line \up0 \expndtw-6\charscalex100 display rs
t and then scanning of items row by row and column by \line \up0 \expndtw-9\char
scalex96 column. The scanning pattern chosen is determined by skill of the indi\line \up0 \expndtw-10\charscalex97 vidual AAC user and by speed of communicatio
n. The amount of time \line \up0 \expndtw-9\charscalex92 in between vocabulary c
hoices is called scan timing. Scan timing provides \line \up0 \expndtw-5\charsca
lex100 the AAC user with enough time to activate his or her switch. Scan \line \
up0 \expndtw-9\charscalex94 timing is adjusted to accommodate the skills of the
AAC user to produce \line \up0 \expndtw-10\charscalex90 accurate selection of ta
rgeted vocabulary items. \par\pard\qj \li1286\ri959\sb2\sl-258\slmult0\fi478 \up
0 \expndtw-10\charscalex95 Various scan types are available in electronic
communication \line \up0 \expndtw-10\charscalex93 devices. W|th auto scan the v
ocabulary items are automatically scanned \line \up0 \expndtw-9\charscalex93 in
a preset time-dependent pattern until the AAC user activates his or her \line \u
p0 \expndtw-10\charscalex93 switch to make a selection. Inverse scanning is used
when an AAC user \line \up0 \expndtw-9\charscalex94 can better release a switch
, then activate it. Scanning begins in a preset \line \up0 \expndtw-10\charscale
x96 time-dependent pattern when the AAC user activates his or her switch \line \
up0 \expndtw-9\charscalex93 and a selection is made upon release of the switch.
Step scan is not time \line \up0 \expndtw-7\charscalex100 dependent. The step sc
an is controlled by the AAC user, not by the \line \up0 \expndtw-9\charscalex93
passage of time. The user scans vocabulary items along a preset pattern \line \u
p0 \expndtw-9\charscalex97 with each activation of his or her switch. A selectio
n is made when the \line \up0 \expndtw-7\charscalex100 user either stops hitting
the switch for a predetermined period or hits \line \up0 \expndtw-10\charscalex
90 a second switch. \par\pard\qj \li1286\ri960\sb1\sl-260\slmult0\fi478 \up0 \ex
pndtw-10\charscalex95 Auditory scanning of vocabulary items is an option on some
elec\up0 \expndtw-9\charscalex93 tronic devices. It provides the individual wit
h verbal prompts or cues (i.e., \up0 \expndtw-9\charscalex100 label) and the vis
ual scanning of vocabulary items. Auditory scanning \up0 \expndtw-10\charscalex9
6 provides the AAC user with additional feedback to help cue him or her \up0 \ex

pndtw-9\charscalex94 to the choices that are being scanned. It can be used to fa

cilitate training \up0 \expndtw-9\charscalex98 for scanning, as extra cues for u
sers who are cognitively impaired, for \up0 \expndtw-9\charscalex94 those who ar
e more auditory learners than visual learners, and for those \up0 \expndtw-10\ch
arscalex94 who are visually impaired.
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bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz95\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
242}{\bkmkend Pg242}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2663 \up0 \expndtw-10\char
scalex97 \ul0\nosupersub\cf2\f3\fs22 222\tab \up0 \expndtw-8\charscalex97 \ul0\n
osupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling\p
ar\pard\ql \li2421\sb0\sl-260\slmult0 \par\pard\ql\li2421\ri1611\sb90\sl-260\slm
ult0\tx2955 \up0 \expndtw0\charscalex105 \ul0\nosupersub\cf7\f8\fs24 AUGMENTATIV
E AND ALTERNATIVE \line\tab \up0 \expndtw0\charscalex101 COMMUNICATION SYSTEMS \
par\pard\qj \li1551\ri694\sb257\sl-264\slmult0\fi478 \up0 \expndtw-10\charscalex
91 \ul0\nosupersub\cf2\f3\fs22 Avariety of AAC systems are currently available.
All systems are set \line \up0 \expndtw-10\charscalex92 up to work toward a comm
on goal: to improve expressive language skills \line \up0 \expndtw-10\charscalex
97 and functional communication. There are two basic types of AAC sys-\line \up0
\expndtw-10\charscalex92 tems: manual communication systems and electronic
communication \line \up0 \expndtw-10\charscalex95 systems. Usually individuals
have both manual and electronic systems, \line \up0 \expndtw-7\charscalex100 wh
ich are used at dierent times and in dierent environments. Both \line \up0 \expndt
w-10\charscalex93 manual and electronic communication systems have various
symbol \line \up0 \expndtw-10\charscalex94 types as well as symbol grids. The
main dierence between the types is \line \up0 \expndtw-9\charscalex95 that one is
electronic and one is not. Another dierence is in the number \line \up0 \expndtw
-9\charscalex96 of features available. Manual communication systems are t
ypically \line \up0 \expndtw-9\charscalex100 designed from scratch for a specic i
ndividual and his or her commu-\line \up0 \expndtw-9\charscalex92 nication, phys
ical, and sensory (i.e., visual and hearing) needs. Electronic \line \up0 \expnd
tw-9\charscalex92 communication systems are manufactured with a number of featur
es. It is \line \up0 \expndtw-9\charscalex93 then up to the AAC user\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s support sta (i.e., the spe
ech-language pathol-\line \up0 \expndtw-9\charscalex97 ogist and assistive techn
ology practitioner) to customize the system to \line \up0 \expndtw-9\charscalex9
3 meet his or her communication, physical, and sensory needs. The simpli-\line \
up0 \expndtw-9\charscalex97 city or complexity of a user\ul0\nosupersub\cf11\
f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s communication system, whether
it is \line \up0 \expndtw-9\charscalex92 manual or electronic, depends on his o
r her cognitive, receptive language, \line \up0 \expndtw-9\charscalex94 visual,
and physical skills and expressive needs (i.e., amount of vocabu-\line \up0 \exp
ndtw-10\charscalex90 lary needed). \par\pard\qj \li1551\ri696\sb0\sl-263\slmult0
\fi478 \up0 \expndtw-10\charscalex93 Both electronic and manual communication sy
stems may use simi-\line \up0 \expndtw-9\charscalex95 lar vocabulary retrieval m
ethods. A single vocabulary selection can pro-\line \up0 \expndtw-9\charscalex90
duce a single letter (e.g.,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\no
supersub\cf2\f3\fs22 w\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersu
b\cf2\f3\fs22 ), a word (e.g.,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\
nosupersub\cf2\f3\fs22 want\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosu

persub\cf2\f3\fs22 ), a phrase, (e.g.\ul0\nosupersub\cf11\f12\fs22 \u8216?\u821

6?\ul0\nosupersub\cf2\f3\fs22 I want \line \up0 \expndtw-9\charscalex92 to go\ul
0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 ), a senten
ce (e.g.,\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs2
2 I want to go to the park\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosup
ersub\cf2\f3\fs22 ), or a whole paragraph \line \up0 \expndtw-9\charscalex93 (e.
g., the Pledge of Allegiance). Vocabulary items can be represented by \line \up0
\expndtw-9\charscalex95 individual objects, photographs, picture symbols, phras
es, single words, \line \up0 \expndtw-10\charscalex91 or letters. \par\pard\qj \
li1551\ri696\sb0\sl-263\slmult0\fi478 \up0 \expndtw-10\charscalex93 To ensure th
at an individual has the vocabulary needed to meet all \line \up0 \expndtw-8\cha
rscalex100 of his or her communicative needs in all environments, a vocabulary \
line \up0 \expndtw-9\charscalex95 analysis should be conducted. This entails
getting vocabulary items \line \up0 \expndtw-9\charscalex94 from family memb
ers, therapists, teachers, employers, and other signi-\line \up0 \expndtw-9\chars
calex97 cant people in the individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\n
osupersub\cf2\f3\fs22 s life across all environments. Information \line \up0 \ex
pndtw-9\charscalex96 may be retrieved through the use of phone calls, l
ists, prewritten \line \up0 \expndtw-9\charscalex96 forms, or e-mails. In order
to provide the individual with the necessary
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
243}{\bkmkend Pg243}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7192 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 223\par\pard\qj \li
1286\sb0\sl-250\slmult0 \par\pard\qj\li1286\ri960\sb60\sl-250\slmult0 \up0 \expn
dtw-6\charscalex100 vocabulary to communicate in all environments it is essentia
l to get \line \up0 \expndtw-7\charscalex100 information from all potential comm
unication partners. This includes \line \up0 \expndtw-9\charscalex100 communicat
ion interactions that may take place daily \up0 \expndtw-10\charscalex94 (
e.g., hello \par\pard\ql \li1286\sb8\sl-253\slmult0 \up0 \expndtw-10\charscalex
91 routines) or once a year (e.g., wishing someone happy holidays). \par\pard\qj
\li1286\ri959\sb2\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex95 Vocabulary
items can be organized in dierent ways on a commu-\line \up0 \expndtw-10\charsca
lex95 nication system. Individual-centered communication boards or displays \lin
e \up0 \expndtw-10\charscalex95 are designed with specic vocabulary to meet the n
eeds of a particular \line \up0 \expndtw-9\charscalex92 AAC user (e.g., a sports
caster would have vocabulary words to talk about \line \up0 \expndtw-10\charscal
ex94 sports, whereas a chef needs an extensive food vocabulary). They also \line
\up0 \expndtw-10\charscalex94 contain commonly used words and phrases (e.g., h
usband\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s name an
d \line \up0 \expndtw-9\charscalex92 \ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216
?\ul0\nosupersub\cf2\f3\fs22 I need help\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8
217?\ul0\nosupersub\cf2\f3\fs22 ). These boards or displays are composed of the
AAC user\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s \line
\up0 \expndtw-10\charscalex95 primary and most important vocabulary items. Othe
r boards or displays \line \up0 \expndtw-8\charscalex100 are constructed with vo
cabulary words that are specic to an activity \line \up0 \expndtw-9\charscalex97
regardless of the individual user (e.g., bubbles or an art project); these \line

\up0 \expndtw-9\charscalex90 are called activity-centered boards or displays. O

ther boards or displays are \line \up0 \expndtw-9\charscalex97 category based (e
.g., food or clothing). Category and activity-centered \line \up0 \expndtw-10\ch
arscalex95 boards are composed of secondary vocabulary items for the AAC user. \
line \up0 \expndtw-10\charscalex95 These vocabulary items are environment specic
and may not be used \line \up0 \expndtw-9\charscalex100 daily. Some communicat
ion systems include both individual- and \line \up0 \expndtw-10\charscalex9
3 activity-centered communication boards or displays. \par\pard\qj \li1286\ri959
\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex95 Individual and activitycentered displays may be organized in var-\line \up0 \expndtw-9\charscalex95 iou
s ways. One way to enhance retrieval of vocabulary items is by color \line \up0
\expndtw-9\charscalex95 coding according to parts of speech. This enables
the AAC user to \line \up0 \expndtw-9\charscalex95 quickly locate items base
d on grammar and colors. For example, if \line \up0 \expndtw-8\charscalex1
00 nouns are yellow and verbs are pink, an AAC user would look at the \line \up0
\expndtw-9\charscalex100 symbols with a yellow background to nd\ul0\nosupersub\
cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 hamburger.\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 Vocabulary \line \u
p0 \expndtw-9\charscalex91 items can be set up within a display so that all part
s of speech are together \line \up0 \expndtw-6\charscalex100 and in order, from
left to right, to formulate a grammatically correct \line \up0 \expndtw-9\charsc
alex92 sentence (i.e., vocabulary items representing pronouns, verbs, and nouns
\line \up0 \expndtw-8\charscalex100 would be placed in columns from left to righ
t). Some communication \line \up0 \expndtw-9\charscalex91 displays are produced
so that needed vocabulary items are placed in order \line \up0 \expndtw-8\charsc
alex100 from left to right following the script of the communication interaction
. \line \up0 \expndtw-10\charscalex95 For example, a greetings overlay may conta
in the following vocabulary \line \up0 \expndtw-6\charscalex100 in this order fr
om left to right:\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf
2\f3\fs22 Hello,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \u8216?\u8216?\ul0\
nosupersub\cf2\f3\fs22 How are you?,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?
\u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 I am ne,\ul0\nosupersub\cf11\f12\fs22
\u8217?\u8217? \line \up0 \expndtw-9\charscalex94 \u8216?\u8216?\ul0\nosupersub
\cf2\f3\fs22 What did you do this weekend?,\ul0\nosupersub\cf11\f12\fs22 \u8217?
\u8217? \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 I had fun this weekend,\ul0\no
supersub\cf11\f12\fs22 \u8217?\u8217? \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22
Goodbye,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217? \line \up0 \expndtw-10\char
scalex87 \ul0\nosupersub\cf2\f3\fs22 and\ul0\nosupersub\cf11\f12\fs22 \u8216?\u
8216?\ul0\nosupersub\cf2\f3\fs22 See you soon.\ul0\nosupersub\cf11\f12\fs22 \u82
17?\u8217? \par\pard\qj \li1286\ri962\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\
charscalex95 \ul0\nosupersub\cf2\f3\fs22 Communication displays, whether individ
ual- or activity-centered, \line \up0 \expndtw-10\charscalex93 may be done in on
e or more languages (e.g., English words to converse
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz94\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
244}{\bkmkend Pg244}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2665 \up0 \expndtw-10\char
scalex100 \ul0\nosupersub\cf2\f3\fs22 224\tab \up0 \expndtw-8\charscalex100 \ul0
\nosupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling
\par\pard\qj \li1551\sb0\sl-257\slmult0 \par\pard\qj\li1551\ri696\sb75\sl-257\sl

mult0 \up0 \expndtw-10\charscalex96 \ul0\nosupersub\cf2\f3\fs22 with peers and P

olish to converse with family members in Poland who \line \up0 \expndtw-8\charsc
alex100 do not understand English). W|th manual systems, the production of \line
\up0 \expndtw-10\charscalex92 various languages is rather simple and depends on
ly on nding someone \line \up0 \expndtw-9\charscalex94 who can write in those lan
guages. Using various languages in electronic \line \up0 \expndtw-9\charscalex10
0 systems with voice output is more complicated. The electronic device \line \up
0 \expndtw-9\charscalex93 itself must have that language as an included
feature, the ability to \line \up0 \expndtw-6\charscalex100 program in a new
language, or the ability to alter how words sound \line \up0 \expndtw-10\charsca
lex92 phonetically. \par\pard\qj \li1551\ri695\sb3\sl-258\slmult0\fi478 \up0 \ex
pndtw-10\charscalex96 The amount of vocabulary needed in an AAC user\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s communica-\line \up0 \exp
ndtw-10\charscalex93 tion system depends on his or her receptive language skills
and commu-\line \up0 \expndtw-9\charscalex93 nication needs. Some individuals m
ay present with speech that is usually \line \up0 \expndtw-10\charscalex96 under
stood. He or she may only need a few words on an AAC system \line \up0 \expndtw10\charscalex95 that can be used when a breakdown in communication occurs (i.e.,
the \line \up0 \expndtw-10\charscalex96 communication partner does not underst
and the AAC user\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22
s speech). \line \up0 \expndtw-10\charscalex94 Others may exhibit more unintell
igible speech and may be rarely under-\line \up0 \expndtw-10\charscalex92 stood
by listeners. These individuals would have communication systems \line \up0 \exp
ndtw-10\charscalex97 that incorporate a lot of vocabulary to accommodate his or
her needs. \line \up0 \expndtw-7\charscalex100 Communication should be multimoda
l; more than one mode can be \line \up0 \expndtw-9\charscalex100 used for the ex
pression of language. For example, an AAC user may \line \up0 \expndtw-7\charsca
lex100 signal yes or no responses by the use of traditional head nods, may \line
\up0 \expndtw-10\charscalex97 request using symbols, and may vocalize to gain a
ttention. When one \line \up0 \expndtw-10\charscalex94 designs a communication s
ystem, a specic vocabulary item should not \line \up0 \expndtw-9\charscalex93 be
repeated unless one or more of the AAC user\ul0\nosupersub\cf11\f12\fs22 \u8217?
\ul0\nosupersub\cf2\f3\fs22 s partners do not under-\line \up0 \expndtw-7\charsc
alex100 stand it. For example, an AAC user who is literate may have a letter \li
ne \up0 \expndtw-10\charscalex92 board. Although the user can spell out messages
, he or she may need to \line \up0 \expndtw-10\charscalex95 have symbol represen
tation of vocabulary items to communicate with a \line \up0 \expndtw-10\charscal
ex96 nonliterate peer or communication partner. \par\pard\qj \li1551\ri694\sb1\s
l-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 Vocabulary expansion technique
s are ways that vocabulary can be \line \up0 \expndtw-10\charscalex93 retrieved
quickly in both electronic and manual communication systems. \line \up0 \expndtw
-9\charscalex91 Vocabulary expansion techniques are rate enhancement featu
res that \line \up0 \expndtw-10\charscalex95 speed up the communication rate of
the AAC user, which in turn saves \line \up0 \expndtw-10\charscalex92 time and
energy (fewer keystrokes or a decreased number of vocabulary \line \up0 \expndtw
-9\charscalex89 selections needed to produce a message). Included are abbreviati
on expan-\line \up0 \expndtw-6\charscalex100 sion, memory keys and built-in phra
ses, word completion and word \line \up0 \expndtw-10\charscalex93 prediction, pa
ge linking, levels, and semantic compaction. \par\pard\qj \li1551\ri695\sb0\sl-2
60\slmult0\fi478 \up0 \expndtw-10\charscalex95 Abbreviation expansion, memory ke
ys, les, and built-in phrases \line \up0 \expndtw-10\charscalex96 are techniques
in which a combination of letters or numbers represent \line \up0 \expndtw-10\c
harscalex97 a phrase, sentence, or paragraph. For example,\ul0\nosupersub\cf11\f
12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 HB\ul0\nosupersub\cf11\f12\fs
22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 when expanded
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz87\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}

{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}

{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
245}{\bkmkend Pg245}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7192 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 225\par\pard\qj \li
1286\sb0\sl-258\slmult0 \par\pard\qj\li1286\ri959\sb45\sl-258\slmult0 \up0 \expn
dtw-9\charscalex96 depicts the message\ul0\nosupersub\cf11\f12\fs22 \u8216?\u82
16?\ul0\nosupersub\cf2\f3\fs22 Hey Babe,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8
217?\ul0\nosupersub\cf2\f3\fs22 the phrase\ul0\nosupersub\cf11\f12\fs22 \u8216
?\u8216?\ul0\nosupersub\cf2\f3\fs22 I want to go to the bath-\line \up0 \expndtw
-10\charscalex93 room\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub
\cf2\f3\fs22 can be condensed into two letters and an expansion key\ul0\nosuper
sub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 WB,\ul0\nosupersub\c
f11\f12\fs22 \u8217?\u8217? \line \up0 \expndtw-10\charscalex95 \ul0\nosupersub\
cf2\f3\fs22 and the Pledge of Allegiance may be shortened to the expansion\ul0\n
osupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 PA.\ul0\nosup
ersub\cf11\f12\fs22 \u8217?\u8217? \line \up0 \expndtw-10\charscalex92 \ul0\nosu
persub\cf2\f3\fs22 Abbreviated expansions may also be used for common words or p
hrases \line \up0 \expndtw-10\charscalex94 that the user often misspells. W|th m
anual systems, once the AAC user \line \up0 \expndtw-9\charscalex93 produces an
abbreviation expansion, his or her partner needs to look at a \line \up0 \expndt
w-9\charscalex96 chart or book that lists and denes all of the user\ul0\nosupersu
b\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s abbreviation expan-\line \u
p0 \expndtw-10\charscalex95 sions. On electronic systems, once the abbreviation
expansion is com-\line \up0 \expndtw-9\charscalex91 plete, the entire message
is produced. Some electronic devices have \line \up0 \expndtw-9\charscale
x94 another rate enhancement feature called memory keys or les or built-in \line
\up0 \expndtw-9\charscalex93 phrases. These can also store messages of varying l
ength (up to a small \line \up0 \expndtw-9\charscalex93 report) and are accessed
via one or two keystrokes. Abbreviation expan-\line \up0 \expndtw-10\charscalex
97 sion, memory keys, and les can be programmed by the user. Built-in \line \up0
\expndtw-10\charscalex92 phrases are typically preprogrammed by the device manuf
acturer. \par\pard\qj \li1286\ri959\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\ch
arscalex94 Word completion and word prediction are rate-enhancement tech-\line \
up0 \expndtw-9\charscalex94 niques that are used by literate AAC users. Word com
pletion attempts to \line \up0 \expndtw-8\charscalex100 predict the word the use
r is beginning to spell. As a letter is selected, \line \up0 \expndtw-9\charscal
ex92 words that start with that letter are presented to the user. For example, a
s \line \up0 \expndtw-9\charscalex97 one types the letter\ul0\nosupersub\cf11\f1
2\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 h\ul0\nosupersub\cf11\f12\fs2
2 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 the words\ul0\nosupersub\cf11\f12\f
s22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 home,\ul0\nosupersub\cf11\f12\fs2
2 \u8217?\u8217? \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 hello,\ul0\nosupersu
b\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 and\ul0\nosupersub\cf
11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 hat\ul0\nosupersub\cf11\f
12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 may be \line \up0 \expndtw-9\
charscalex97 presented. When the individual adds the letter\ul0\nosupersub\cf11\
f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 o\ul0\nosupersub\cf11\f12\f
s22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 the words\ul0\nosupersub\cf11\f12
\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 home,\ul0\nosupersub\cf11\f12\f
s22 \u8217?\u8217? \line \up0 \expndtw-9\charscalex94 \u8216?\u8216?\ul0\nosuper
sub\cf2\f3\fs22 hope,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub
\cf2\f3\fs22 and\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\c
f2\f3\fs22 honesty\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf

2\f3\fs22 may then be presented. Word prediction also \line \up0 \expndtw7\charscalex100 attempts to predict the next word from the AAC user on the basis
of \line \up0 \expndtw-9\charscalex97 grammatical rules. For example, if the us
er spells the word\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\c
f2\f3\fs22 they,\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\
f3\fs22 the \line \up0 \expndtw-7\charscalex100 words\ul0\nosupersub\cf11\f12\f
s22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 are\ul0\nosupersub\cf11\f12\fs22
\u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 and\ul0\nosupersub\cf11\f12\fs22 \u8
216?\u8216?\ul0\nosupersub\cf2\f3\fs22 will\ul0\nosupersub\cf11\f12\fs22 \u8217?
\u8217?\ul0\nosupersub\cf2\f3\fs22 may be predicted but not the word\ul0\nosupe
rsub\cf11\f12\fs22 \u8216?\u8216?\ul0\nosupersub\cf2\f3\fs22 is.\ul0\nosupersub
\cf11\f12\fs22 \u8217?\u8217?\ul0\nosupersub\cf2\f3\fs22 Word \line \up0 \expnd
tw-10\charscalex95 completion and word prediction are based on the frequency of
use of a \line \up0 \expndtw-10\charscalex95 standard vocabulary set (based on t
he general population) or a custom \line \up0 \expndtw-10\charscalex91 vocabular
y set \up0 \expndtw-10\charscalex93 (user\ul0\nosupersub\cf11\f12\fs22 \u8217?\
ul0\nosupersub\cf2\f3\fs22 s specic way of using and combining words). \li
ne \up0 \expndtw-10\charscalex96 Electronic systems usually provide the AAC user
with word completion \line \up0 \expndtw-8\charscalex100 and word prediction ch
oices visually and/or auditorally. W|th manual \line \up0 \expndtw-8\charscalex1
00 systems, the AAC user relies on his or her communication partner to \line \up
0 \expndtw-9\charscalex94 verbally\ul0\nosupersub\cf11\f12\fs22 \u8216?\u8216?\
ul0\nosupersub\cf2\f3\fs22 guess\ul0\nosupersub\cf11\f12\fs22 \u8217?\u8217?\ul0
\nosupersub\cf2\f3\fs22 the partially spelled word or predict the next word. \p
ar\pard\qj \li1286\ri959\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91
Page linking is a technique used to expand vocabulary by the use of \line \up0 \
expndtw-9\charscalex100 categories or activities. When an AAC user selects a cat
egory, a new \line \up0 \expndtw-9\charscalex94 communication board or display i
s presented to the user with vocabulary \line \up0 \expndtw-9\charscalex95 specic
to that category. For example, an individual wanting to eat \line \up0
\expndtw-6\charscalex100 would select or page link to his or her food page. On t
hat page, the \line \up0 \expndtw-9\charscalex94 AAC user would have a listing o
f all favorite foods.W|th manual systems, \line \up0 \expndtw-10\charscalex94 th
e changing of pages or boards may be done manually by the AAC user
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz118\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
246}{\bkmkend Pg246}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2665 \up0 \expndtw-10\char
scalex100 \ul0\nosupersub\cf2\f3\fs22 226\tab \up0 \expndtw-8\charscalex100 \ul0
\nosupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling
\par\pard\qj \li1551\sb0\sl-253\slmult0 \par\pard\qj\li1551\ri696\sb82\sl-253\sl
mult0 \up0 \expndtw-10\charscalex97 \ul0\nosupersub\cf2\f3\fs22 or by his or her
communication partner. W|th electronic devices, page \up0 \expndtw-9\charscalex
94 linking is done automatically.When the AAC user selects the category or \up0
\expndtw-9\charscalex94 activity, the page opens up, and vocabulary choices with
in that category \up0 \expndtw-10\charscalex89 are displayed to the user. \par\p
ard\qj \li1551\ri694\sb2\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex91 Leve
ls are another vocabulary expansion technique that provide the \line \up0 \expnd
tw-9\charscalex93 user with additional vocabulary items. Some electronic systems
have the \line \up0 \expndtw-10\charscalex92 ability to have more than one comm

unication board or page programmed \line \up0 \expndtw-10\charscalex96 into it a

t a time. Each programmed board is a level. The levels may be \line \up0 \expndt
w-10\charscalex96 changed manually by the user or communication partner by physi
cally \line \up0 \expndtw-10\charscalex94 changing the communication board on th
e display and turning a knob to \line \up0 \expndtw-10\charscalex94 change to th
e desired level that has the corresponding preprogrammed \line \up0 \expndtw-9\c
harscalex93 vocabulary in it. Other electronic systems can change to the desired
level \line \up0 \expndtw-9\charscalex95 when a specic selection is made. Then i
t is up to the user or partner to \line \up0 \expndtw-10\charscalex93 simply cha
nge the communication board. Instead of having to physically \line \up0 \expndtw
-9\charscalex90 change a board, some communication displays are designed to pres
ent the \line \up0 \expndtw-9\charscalex96 user with all levels at one time. For
example, a cell may be divided into \line \up0 \expndtw-9\charscalex91 three se
ctions, each representing vocabulary items from a dierent level. A \line \up0 \ex
pndtw-9\charscalex97 user selects and locks himself or herself into a level. All
selections will \line \up0 \expndtw-9\charscalex95 contain vocabulary from th
at locked-in level until the user changes \line \up0 \expndtw-9\charscalex
94 levels. Manual systems are typically designed using the latter method of \lin
e \up0 \expndtw-10\charscalex92 presenting multiple levels on one communication
board. \par\pard\qj \li1551\ri694\sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\char
scalex89 Semantic compaction (Unity) (Badman et al., 1995) is another vocab-\lin
e \up0 \expndtw-10\charscalex92 ulary enhancement technique. Semantic compact
ion uses symbols or \line \up0 \expndtw-9\charscalex90 icons that have mul
tiple meanings, as discussed earlier. Because one \line \up0 \expndtw-10\c
harscalex95 symbol or icon represents multiple words or phrases, fewer icons nee
d \line \up0 \expndtw-9\charscalex93 to be presented to the user to express a la
rger vocabulary. Therefore the \line \up0 \expndtw-9\charscalex95 user can quick
ly scan his or her few icons to produce unlimited vocabu-\line \up0 \expndtw-9\c
harscalex92 lary. Some systems contain specic icon combinations, and others let t
he \line \up0 \expndtw-8\charscalex100 AAC user decide which symbols should be c
ombined to represent a \line \up0 \expndtw-9\charscalex94 specic vocabulary ite
m. A few electronic systems contain semantic \line \up0 \expndtw-10\charsca
lex92 compaction. They will produce the desired message once the entire com-\lin
e \up0 \expndtw-9\charscalex92 bination of symbols has been completed. Some elec
tronic devices will aid \line \up0 \expndtw-6\charscalex100 the AAC user by a fe
ature called icon prediction. When a symbol is \line \up0 \expndtw-9\charscalex1
00 chosen, only the icons that can be combined with the original chosen \line \u
p0 \expndtw-9\charscalex95 icon are highlighted (i.e., by a light or by a change
in backlight). Manual \line \up0 \expndtw-10\charscalex94 systems require that
the communication partner or listener and the AAC \line \up0 \expndtw-9\charscal
ex91 user learn semantic compaction. It is up to the listener to read and expand
\line \up0 \expndtw-10\charscalex91 the semantic compaction produced by the AAC
user.
{\shp {\*\shpinst\shpleft1551\shptop1147\shpright7768\shpbottom1167\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz89\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
247}{\bkmkend Pg247}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7192 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 227\par\pard\qj \li
1286\sb0\sl-263\slmult0 \par\pard\qj\li1286\ri959\sb36\sl-263\slmult0\fi478 \up0

\expndtw-7\charscalex100 A communication device refers to the individual

electronic \line \up0 \expndtw-10\charscalex92 device, whereas a communication
system consists of the manual or elec-\line \up0 \expndtw-9\charscalex93 tronic
communication device and its accessories. Accessories to facilitate \line \up0 \
expndtw-9\charscalex100 functional use of the manual system or electronic device
may include \line \up0 \expndtw-9\charscalex95 mounting systems, access method
(i.e., pointer, laser, optical indicator, \line \up0 \expndtw-10\charscalex97 s
witch, joystick, or mouse emulation), speakers, keyguards, and carry \line \up0
\expndtw-10\charscalex75 case. \par\pard\ql \li2668\sb0\sl-207\slmult0 \par\pard
\ql\li2668\sb0\sl-207\slmult0 \par\pard\ql\li2668\sb0\sl-207\slmult0 \par\pard\q
l\li2668\sb43\sl-207\slmult0 \up0 \expndtw0\charscalex104 \ul0\nosupersub\cf7\f8
\fs24 M\ul0\nosupersub\cf31\f32\fs17 ANUAL\ul0\nosupersub\cf7\f8\fs24 C\ul0\nos
upersub\cf31\f32\fs17 OMMUNICATION\ul0\nosupersub\cf7\f8\fs24 S\ul0\nosupersub\
cf31\f32\fs17 YSTEMS \par\pard\qj \li1286\sb0\sl-263\slmult0 \par\pard\qj\li1286
\ri959\sb4\sl-263\slmult0\fi478 \up0 \expndtw-8\charscalex100 \ul0\nosupersub\cf
2\f3\fs22 Manual communication systems are nonelectronic forms of \line \u
p0 \expndtw-7\charscalex100 AAC that are customized for a particular individual,
taking his or her \line \up0 \expndtw-9\charscalex90 specic skills, vocabulary n
eeds, access issues, and communication needs \line \up0 \expndtw-7\charscalex100
into account. They can be extremely accommodating with regard to \line \up0 \ex
pndtw-10\charscalex96 size and shape. Manual communication systems may contain o
ne or a \line \up0 \expndtw-10\charscalex95 combination of symbol sets (objects,
photographs, pictures or symbols, \line \up0 \expndtw-10\charscalex96 letters,
words, and phrases) on the same system. They do not provide \line \up0 \expndtw9\charscalex100 voice output and depend on the close proximity of the listener t
o read \line \up0 \expndtw-10\charscalex95 the AAC user\ul0\nosupersub\cf11\f12\
fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s vocabulary selections. Manual communic
ation systems \line \up0 \expndtw-10\charscalex96 may be the individual\ul0\n
osupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s primary means of
communication or may \line \up0 \expndtw-9\charscalex100 be used as a backup
method when his or her electronic device is not \line \up0 \expndtw-10\charscal
ex85 available. \par\pard\qj \li1286\ri959\sb0\sl-264\slmult0\fi478 \up0 \expndt
w-10\charscalex95 Vocabulary items on manual communication systems can be
\line \up0 \expndtw-7\charscalex100 selected directly or indirectly. Direct acc
ess consists of pointing with \line \up0 \expndtw-5\charscalex100 a nger or othe
r body part, the use of a pointer to directly touch a \line \up0 \expndtw-4\char
scalex100 vocabulary item (e.g., a mouth stick that is held in the mouth or a \
line \up0 \expndtw-9\charscalex98 pointer attached to a hand splint), or the use
of an indicator (e.g., light \line \up0 \expndtw-9\charscalex96 or laser pointe
r). Keyguards may be used to facilitate accurate access \line \up0 \expndtw-8\c
harscalex100 of vocabulary items when needed. An indicator can be held
or \line \up0 \expndtw-9\charscalex98 attached to a body part (i.e., on top of
the head). The indicator is then \line \up0 \expndtw-10\charscalex96 placed on o
r shown on the desired vocabulary item. Manual communi-\line \up0 \expndtw-9\cha
rscalex94 cation systems can also be accessed indirectly. W|th manual or partner
-\line \up0 \expndtw-9\charscalex94 assisted scanning, the communication par
tner or listener scans the \line \up0 \expndtw-10\charscalex96 vocabulary pa
ge for the AAC user (see the earlier section on scanning \line \up0 \expndtw-9\c
harscalex94 techniques). The listener verbally or physically cues the AAC user t
o the \line \up0 \expndtw-10\charscalex94 vocabulary items, and when the AA
C user makes a predetermined
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz99\shplid0
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s

p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s

p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
248}{\bkmkend Pg248}\par\pard\li1551\sb0\sl-253\slmult0\par\pard\li1551\sb0\sl-2
53\slmult0\par\pard\li1551\sb137\sl-253\slmult0\fi0\tx2665 \up0 \expndtw-10\char
scalex100 \ul0\nosupersub\cf2\f3\fs22 228\tab \up0 \expndtw-8\charscalex100 \ul0
\nosupersub\cf5\f6\fs18 Alternative Communication, Amplification, and Counseling
\par\pard\qj \li1551\sb0\sl-240\slmult0 \par\pard\qj\li1551\ri696\sb106\sl-240\s
lmult0 \up0 \expndtw-9\charscalex91 \ul0\nosupersub\cf2\f3\fs22 response the par
tner announces the chosen vocabulary item and waits for \up0 \expndtw-10\charsca
lex91 conrmation. \par\pard\qj \li1551\ri695\sb4\sl-260\slmult0\fi478 \up0 \expnd
tw-10\charscalex96 Manual communication systems consist of communicati
on \line \up0 \expndtw-9\charscalex94 boards or books or wallets and eyega
ze systems. A communication \line \up0 \expndtw-9\charscalex94 board contains
individual displays containing vocabulary items (Fig. 9.1). \line \up0 \expndtw10\charscalex94 Communication boards vary greatly in size; they may be as small
as an \line \up0 \expndtw-9\charscalex95 index card or large enough to cover an
entire lap tray of a wheelchair. A \line \up0 \expndtw-10\charscalex97 communica
tion book or wallet is a collection of individual communica-\line \up0 \expndtw9\charscalex97 tion boards to provide the AAC user with many vocabulary
items. \line \up0 \expndtw-10\charscalex97 Communication books and wallets are d
esigned to be small, portable, \line \up0 \expndtw-8\charscalex100 and lightweig
ht. Communication books can be carried or worn with a \line \up0 \expndtw-9\char
scalex95 strap, like a book bag or purse. Communication wallets are smaller than
\line \up0 \expndtw-10\charscalex95 communication books and can be carried in a
pocket. \par\pard\qj \li1551\ri694\sb2\sl-258\slmult0\fi478 \up0 \expndtw-8\cha
rscalex100 Eyegaze systems can include, but are not limited to, Eye Links \line
\up0 \expndtw-9\charscalex100 (Drinker & Krupo, 1981) and E-TRANs (Beukelma
n & Mirenda, \line \up0 \expndtw-9\charscalex92 1992). Eyegaze systems use
an individual\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s
eyes to point to or select \line \up0 \expndtw-9\charscalex100 vocabulary t
argets. Eye Links are clear displays that provide the AAC \line \up0 \expndtw-9\
charscalex95 user with all letters of the alphabet and some words and functions
(e.g., \line \up0 \expndtw-9\charscalex94 end of word, backspace, and nished) (Fi
g. 9.2). The AAC user points to \line \up0 \expndtw-9\charscalex93 individual le
tters to spell out a word or sentence with his or her eyes. The \line \up0 \expn
dtw-9\charscalex100 communication listener must move the Eye Link around to atte
mpt to \line \up0 \expndtw-9\charscalex94 read the letters that the AAC user\ul0
\nosupersub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s eye is pointing t
o. The listener reads \line \up0 \expndtw-9\charscalex94 these letters by moving
the Eye Link around until he or she makes direct \line \up0 \expndtw-10\charsca
lex95 eye contact with the AAC user. When eye contact is made, the letter in \li
ne \up0 \expndtw-10\charscalex91 between their eyes is the selected vocabulary i
tem. \par\pard\qj \li1551\ri696\sb1\sl-260\slmult0\fi478 \up0 \expndtw-10\charsc
alex96 E-TRANs (Beukelman & Mirenda, 1992) are constructed of clear \up0 \expndt
w-8\charscalex100 Plexiglas or plastic with vocabulary items (i.e., objects, sy
mbols, and \up0 \expndtw-10\charscalex96 words) placed on them (Fig. 9.3). The E
-TRAN is usually placed on an \up0 \expndtw-10\charscalex92 AAC user\ul0\nosuper
sub\cf11\f12\fs22 \u8217?\ul0\nosupersub\cf2\f3\fs22 s wheelchair. The AAC user
looks at a vocabulary item and his \up0 \expndtw-8\charscalex100 or her partner
looks through the opening in the E-TRAN to see what \up0 \expndtw-10\charscalex9
5 vocabulary item the AAC user is looking at. \par\pard\qj \li1551\ri695\sb0\sl260\slmult0\fi478 \up0 \expndtw-9\charscalex100 The E-TRAN (Beukelman & Mirenda,
1992) diers from the Eye \up0 \expndtw-9\charscalex98 Link (Drinker & Krupo, 1981
) in that it is a more independent, station\up0 \expndtw-10\charscalex95 ary for
m of communication; the communication partner or listener does \up0 \expndtw-10\
charscalex96 not have to physically move the communication display around to rea
d \up0 \expndtw-10\charscalex88 the user\ul0\nosupersub\cf11\f12\fs22 \u8217?\ul
0\nosupersub\cf2\f3\fs22 s vocabulary selections. \par\pard\qj \li1551\ri696\sb0
\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex90 There are many advantages an

d disadvantages to the use of manual \up0 \expndtw-10\charscalex91 communication

systems. Some of them are listed in Table 9.2. \par\pard\ql \li5722\sb6\sl-253\
slmult0 \up0 \expndtw-10\charscalex79 Text continues on page 233
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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}
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020{\shp
{\*\shpinst\shpleft0\shptop0\shpright8700\shpbottom13020\shpwr3\shpfblwtxt0\shpz
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{\sp{\sn pVerticies}{\sv 8;4;(0,4464);(5902,4464);(5902,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft1443\shptop8384\shpright1443\shpbottom3920\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz15\shplid1{\sp{\sn shapeType}{\s
v 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\sn
lineWidth}{\sv 14631}}
}}
{\shp {\*\shpinst\shpleft3027\shptop5053\shpright5619\shpbottom6925\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz22\shplid2
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 2592}}{\sp{\sn geoBottom}{\sv 1872}}
{\sp{\sn pVerticies}{\sv 8;4;(0,0);(2592,0);(2592,1872);(0,1872)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 167772
15}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft3027\shptop5053\shpright5619\shpbottom6925\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz30\shplid3
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 2592}}{\sp{\sn geoBottom}{\sv 1872}}{\sp{\sn shapePath}{\sv 4}
}
{\sp{\sn pVerticies}{\sv 8;4;(0,1872);(2592,1872);(2592,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;9;16384;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}

}}
{\shp {\*\shpinst\shpleft3027\shptop6925\shpright3027\shpbottom5053\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz30\shplid4{\sp{\sn shapeType}{\s
v 20}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}{\sp{\sn
lineWidth}{\sv 14631}}
}}
{\shp {\*\shpinst\shpleft1735\shptop4060\shpright2035\shpbottom4570\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz42\shplid5
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 300}}{\sp{\sn geoBottom}{\sv 510}}
{\sp{\sn pVerticies}{\sv 8;10;(0,0);(95,0);(150,175);(205,0);(300,0);(190,300);(
190,510);(105,510);(105,300);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;22;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1732\shptop4063\shpright2031\shpbottom4573\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz55\shplid6
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 299}}{\sp{\sn geoBottom}{\sv 510}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;10;(0,0);(95,0);(150,173);(206,0);(299,0);(192,297);(
192,510);(107,510);(107,297);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;21;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft2010\shptop4195\shpright2240\shpbottom4580\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz81\shplid7
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 230}}{\sp{\sn geoBottom}{\sv 385}}
{\sp{\sn pVerticies}{\sv 8;25;(230,230);(80,230);(85,280);(115,305);(140,290);(1
50,270);(225,280);(185,360);(115,385);(55,365);(15,300);(0,195);(30,55);(65,10);
(110,0);(180,25);(215,95);(230,210);(230,230);(150,160);(140,100);(115,85);(85,1
10);(80,160);(150,160)}}
{\sp{\sn pSegmentInfo}{\sv 2;52;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft2008\shptop4195\shpright2239\shpbottom4582\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz108\shplid8
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 231}}{\sp{\sn geoBottom}{\sv 387}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;29;(231,230);(78,230);(87,281);(99,297);(116,303);(13
8,294);(152,270);(227,284);(207,332);(185,363);(155,381);(114,387);(80,383);(53,
366);(32,339);(14,300);(3,252);(0,195);(8,116);(30,54);(66,14);(111,0);(150,6);(
180,26);(201,54);(218,95);(228,147);(231,213);(231,230)}}
{\sp{\sn pSegmentInfo}{\sv 2;59;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45

824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft2086\shptop4281\shpright2161\shpbottom4356\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz108\shplid9
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 75}}{\sp{\sn geoBottom}{\sv 75}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;10;(75,75);(71,40);(63,16);(51,3);(38,0);(21,6);(9,25
);(0,75);(75,75);(75,75)}}
{\sp{\sn pSegmentInfo}{\sv 2;21;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft2260\shptop4195\shpright2475\shpbottom4580\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz141\shplid10
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 215}}{\sp{\sn geoBottom}{\sv 385}}
{\sp{\sn pVerticies}{\sv 8;32;(0,275);(80,260);(90,300);(115,310);(135,295);(145
,275);(135,250);(100,235);(50,210);(20,175);(10,115);(20,50);(55,10);(110,0);(16
0,10);(190,40);(205,100);(135,110);(125,85);(105,75);(85,85);(80,105);(85,125);(
120,135);(175,160);(205,200);(215,260);(205,320);(170,370);(110,385);(30,355);(0
,275)}}
{\sp{\sn pSegmentInfo}{\sv 2;66;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft2260\shptop4195\shpright2471\shpbottom4582\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz175\shplid11
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 211}}{\sp{\sn geoBottom}{\sv 387}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;41;(0,276);(76,263);(81,285);(89,299);(111,309);(135,
299);(143,276);(134,252);(121,245);(101,237);(66,225);(45,213);(20,176);(8,117);
(20,53);(51,14);(105,0);(136,3);(158,11);(186,42);(206,99);(134,113);(123,86);(1
01,77);(83,84);(76,104);(84,126);(96,132);(117,138);(150,147);(174,159);(203,201
);(211,260);(201,323);(168,369);(143,383);(106,387);(60,380);(30,359);(11,324);(
0,276)}}
{\sp{\sn pSegmentInfo}{\sv 2;83;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6195\shptop4120\shpright6480\shpbottom4630\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz187\shplid12

{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{

\sn geoRight}{\sv 285}}{\sp{\sn geoBottom}{\sv 510}}
{\sp{\sn pVerticies}{\sv 8;11;(0,0);(85,0);(200,280);(200,0);(285,0);(285,510);(
200,510);(85,230);(85,510);(0,510);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;24;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6192\shptop4119\shpright6477\shpbottom4630\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz200\shplid13
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 285}}{\sp{\sn geoBottom}{\sv 511}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;11;(0,0);(85,0);(199,283);(199,0);(285,0);(285,511);(
199,511);(87,231);(87,511);(0,511);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;23;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6525\shptop4250\shpright6775\shpbottom4635\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz220\shplid14
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 250}}{\sp{\sn geoBottom}{\sv 385}}
{\sp{\sn pVerticies}{\sv 8;19;(0,195);(35,55);(125,0);(180,15);(220,65);(250,195
);(215,335);(125,385);(40,340);(0,195);(85,195);(95,270);(125,290);(155,270);(16
5,195);(155,120);(125,100);(95,120);(85,195)}}
{\sp{\sn pSegmentInfo}{\sv 2;40;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6523\shptop4252\shpright6772\shpbottom4638\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz241\shplid15
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 249}}{\sp{\sn geoBottom}{\sv 386}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;17;(0,194);(9,117);(33,54);(72,14);(124,0);(180,17);(
222,65);(243,122);(249,192);(240,270);(216,332);(176,372);(124,386);(77,375);(39
,341);(11,276);(0,194)}}
{\sp{\sn pSegmentInfo}{\sv 2;35;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6605\shptop4350\shpright6688\shpbottom4543\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz241\shplid16
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 83}}{\sp{\sn geoBottom}{\sv 193}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;18;(0,96);(4,139);(12,169);(26,187);(42,193);(59,187)
;(71,169);(80,138);(83,94);(80,52);(71,24);(59,6);(42,0);(26,6);(12,24);(4,52);(

0,96);(0,96)}}
{\sp{\sn pSegmentInfo}{\sv 2;37;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft5565\shptop7555\shpright5765\shpbottom8065\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz253\shplid17
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 200}}{\sp{\sn geoBottom}{\sv 510}}
{\sp{\sn pVerticies}{\sv 8;11;(0,0);(200,0);(200,110);(80,110);(80,200);(185,200
);(185,300);(80,300);(80,510);(0,510);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;24;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft5565\shptop7555\shpright5764\shpbottom8067\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz266\shplid18
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 199}}{\sp{\sn geoBottom}{\sv 512}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;11;(0,0);(199,0);(199,111);(79,111);(79,200);(181,200
);(181,303);(79,303);(79,512);(0,512);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;23;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft5810\shptop7555\shpright5880\shpbottom7650\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz278\shplid19
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 70}}{\sp{\sn geoBottom}{\sv 95}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(70,0);(70,95);(0,95);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft5810\shptop7695\shpright5880\shpbottom8065\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz278\shplid20
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 70}}{\sp{\sn geoBottom}{\sv 370}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(70,0);(70,370);(0,370);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft5806\shptop7555\shpright5878\shpbottom7653\shpfhdr0\shp

bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz291\shplid21
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 72}}{\sp{\sn geoBottom}{\sv 98}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(72,0);(72,98);(0,98);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;11;16384;45824;1;45824;1;45824;1;45824;1;45824;3276
8}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft5806\shptop7696\shpright5878\shpbottom8067\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz291\shplid22
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 72}}{\sp{\sn geoBottom}{\sv 371}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;6;(0,0);(72,0);(72,371);(0,371);(0,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;13;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft5925\shptop7685\shpright6130\shpbottom8065\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz309\shplid23
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 205}}{\sp{\sn geoBottom}{\sv 380}}
{\sp{\sn pVerticies}{\sv 8;17;(0,10);(70,10);(70,70);(100,20);(140,0);(185,35);(
205,145);(205,380);(130,380);(130,175);(125,130);(105,115);(85,130);(75,205);(75
,380);(0,380);(0,10)}}
{\sp{\sn pSegmentInfo}{\sv 2;36;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft5925\shptop7689\shpright6125\shpbottom8067\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz328\shplid24
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 200}}{\sp{\sn geoBottom}{\sv 378}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;23;(0,7);(69,7);(69,69);(84,36);(99,15);(136,0);(163,
7);(184,34);(196,79);(200,142);(200,378);(129,378);(129,174);(127,145);(121,126)
;(102,111);(91,115);(82,130);(76,157);(73,201);(73,378);(0,378);(0,7)}}
{\sp{\sn pSegmentInfo}{\sv 2;47;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6175\shptop7555\shpright6245\shpbottom7650\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz340\shplid25
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 70}}{\sp{\sn geoBottom}{\sv 95}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(70,0);(70,95);(0,95);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}

{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958

6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6175\shptop7695\shpright6245\shpbottom8065\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz340\shplid26
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 70}}{\sp{\sn geoBottom}{\sv 370}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(70,0);(70,370);(0,370);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6172\shptop7555\shpright6244\shpbottom7653\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz353\shplid27
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 72}}{\sp{\sn geoBottom}{\sv 98}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;5;(0,0);(72,0);(72,98);(0,98);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;11;16384;45824;1;45824;1;45824;1;45824;1;45824;3276
8}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6172\shptop7696\shpright6244\shpbottom8067\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz353\shplid28
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 72}}{\sp{\sn geoBottom}{\sv 371}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;6;(0,0);(72,0);(72,371);(0,371);(0,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;13;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6280\shptop7685\shpright6480\shpbottom8075\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz386\shplid29
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 200}}{\sp{\sn geoBottom}{\sv 390}}
{\sp{\sn pVerticies}{\sv 8;32;(0,280);(75,265);(85,300);(105,310);(130,300);(135
,275);(130,255);(95,240);(45,215);(20,180);(10,120);(20,55);(50,15);(100,0);(150
,10);(180,45);(195,100);(125,115);(115,90);(95,75);(80,85);(75,105);(80,125);(11
0,140);(165,160);(195,205);(200,260);(190,325);(160,370);(105,390);(30,360);(0,2
80)}}
{\sp{\sn pSegmentInfo}{\sv 2;66;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6279\shptop7689\shpright6481\shpbottom8076\shpfhdr0\shp

bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz420\shplid30
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 202}}{\sp{\sn geoBottom}{\sv 387}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;39;(0,276);(71,262);(85,298);(106,309);(128,297);(135
,274);(127,250);(115,244);(94,237);(63,223);(43,211);(30,198);(18,175);(7,115);(
19,52);(48,12);(100,0);(151,10);(176,42);(195,99);(126,112);(116,85);(96,75);(78
,84);(71,103);(81,124);(91,130);(111,136);(165,159);(191,201);(202,258);(191,321
);(160,369);(135,382);(101,387);(58,379);(28,358);(10,324);(0,276)}}
{\sp{\sn pSegmentInfo}{\sv 2;79;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6515\shptop7555\shpright6720\shpbottom8065\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz438\shplid31
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 205}}{\sp{\sn geoBottom}{\sv 510}}
{\sp{\sn pVerticies}{\sv 8;17;(0,0);(75,0);(75,190);(105,145);(140,130);(185,165
);(205,275);(205,510);(130,510);(130,305);(125,260);(105,245);(85,260);(75,335);
(75,510);(0,510);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;36;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6514\shptop7555\shpright6717\shpbottom8067\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz457\shplid32
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 203}}{\sp{\sn geoBottom}{\sv 512}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;22;(0,0);(73,0);(73,189);(103,146);(138,134);(165,141
);(185,168);(198,213);(203,276);(203,512);(129,512);(129,308);(128,279);(121,260
);(103,245);(91,249);(83,264);(76,291);(73,335);(73,512);(0,512);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;45;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6750\shptop7685\shpright6970\shpbottom8075\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz483\shplid33
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 220}}{\sp{\sn geoBottom}{\sv 390}}
{\sp{\sn pVerticies}{\sv 8;24;(220,230);(75,230);(85,280);(115,305);(135,295);(1
45,270);(220,285);(180,365);(110,390);(50,370);(15,305);(0,195);(30,55);(110,0);
(175,25);(210,95);(220,215);(220,230);(150,165);(135,105);(110,85);(85,115);(75,
165);(150,165)}}
{\sp{\sn pSegmentInfo}{\sv 2;50;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}
}

{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958

6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6750\shptop7689\shpright6970\shpbottom8076\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz510\shplid34
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 220}}{\sp{\sn geoBottom}{\sv 387}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;28;(220,229);(75,229);(84,280);(95,297);(112,303);(13
2,294);(144,270);(215,282);(197,330);(177,363);(148,381);(109,387);(76,381);(50,
366);(31,339);(15,300);(0,193);(7,115);(28,52);(62,13);(107,0);(145,6);(172,24);
(193,54);(208,94);(217,147);(220,213);(220,229)}}
{\sp{\sn pSegmentInfo}{\sv 2;57;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6825\shptop7773\shpright6897\shpbottom7849\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz510\shplid35
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 72}}{\sp{\sn geoBottom}{\sv 76}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;9;(72,76);(67,40);(60,18);(35,0);(20,6);(9,27);(0,76)
;(72,76);(72,76)}}
{\sp{\sn pSegmentInfo}{\sv 2;19;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft6995\shptop7555\shpright7205\shpbottom8075\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz535\shplid36
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 210}}{\sp{\sn geoBottom}{\sv 520}}
{\sp{\sn pVerticies}{\sv 8;23;(210,0);(210,510);(145,510);(145,455);(115,505);(8
0,520);(25,460);(0,320);(25,180);(80,130);(110,145);(135,175);(135,0);(210,0);(1
35,325);(130,260);(105,240);(85,260);(75,330);(85,395);(105,415);(130,395);(135,
325)}}
{\sp{\sn pSegmentInfo}{\sv 2;48;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft6994\shptop7555\shpright7204\shpbottom8076\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz561\shplid37
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 210}}{\sp{\sn geoBottom}{\sv 521}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;20;(210,0);(210,512);(141,512);(141,458);(128,486);(1
16,504);(99,516);(81,521);(46,506);(21,464);(6,399);(0,323);(6,242);(23,182);(50
,146);(81,134);(111,144);(136,177);(136,0);(210,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;41;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45

824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft7067\shptop7795\shpright7130\shpbottom7972\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz561\shplid38
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 63}}{\sp{\sn geoBottom}{\sv 177}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;18;(63,86);(62,48);(55,20);(44,5);(30,0);(18,5);(8,20
);(2,48);(0,90);(3,128);(10,155);(18,171);(32,177);(44,171);(55,155);(62,126);(6
3,86);(63,86)}}
{\sp{\sn pSegmentInfo}{\sv 2;37;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft1735\shptop7500\shpright2045\shpbottom8010\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz576\shplid39
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 310}}{\sp{\sn geoBottom}{\sv 510}}
{\sp{\sn pVerticies}{\sv 8;14;(0,0);(110,0);(155,310);(195,0);(310,0);(310,510);
(240,510);(240,120);(185,510);(120,510);(70,120);(70,510);(0,510);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;30;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1732\shptop7500\shpright2044\shpbottom8011\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz592\shplid40
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 312}}{\sp{\sn geoBottom}{\sv 511}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;14;(0,0);(113,0);(155,310);(198,0);(312,0);(312,511);
(242,511);(242,121);(188,511);(123,511);(71,121);(71,511);(0,511);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;29;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft2085\shptop7630\shpright2315\shpbottom8020\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz612\shplid41
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 230}}{\sp{\sn geoBottom}{\sv 390}}
{\sp{\sn pVerticies}{\sv 8;19;(0,195);(30,55);(115,0);(170,15);(205,65);(230,195
);(200,335);(115,390);(35,345);(0,195);(75,195);(90,270);(115,290);(145,270);(15
5,195);(145,120);(115,100);(90,125);(75,195)}}
{\sp{\sn pSegmentInfo}{\sv 2;40;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv

1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}

}}
{\shp {\*\shpinst\shpleft2083\shptop7633\shpright2314\shpbottom8020\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz633\shplid42
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 231}}{\sp{\sn geoBottom}{\sv 387}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;17;(0,194);(9,116);(32,54);(68,14);(114,0);(168,17);(
207,65);(225,122);(231,192);(223,270);(200,332);(163,372);(114,387);(71,375);(36
,341);(9,276);(0,194)}}
{\sp{\sn pSegmentInfo}{\sv 2;35;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft2161\shptop7731\shpright2236\shpbottom7923\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz633\shplid43
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 75}}{\sp{\sn geoBottom}{\sv 192}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;18;(0,96);(3,139);(11,169);(23,186);(38,192);(54,187)
;(65,169);(72,139);(75,94);(72,51);(65,22);(53,4);(38,0);(23,6);(11,24);(3,52);(
0,96);(0,96)}}
{\sp{\sn pSegmentInfo}{\sv 2;37;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft2355\shptop7630\shpright2510\shpbottom8010\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz647\shplid44
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 155}}{\sp{\sn geoBottom}{\sv 380}}
{\sp{\sn pVerticies}{\sv 8;13;(0,10);(70,10);(70,70);(90,15);(120,0);(155,20);(1
35,120);(110,110);(90,135);(75,255);(75,380);(0,380);(0,10)}}
{\sp{\sn pSegmentInfo}{\sv 2;28;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft2351\shptop7633\shpright2509\shpbottom8011\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz662\shplid45
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 158}}{\sp{\sn geoBottom}{\sv 378}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;17;(0,8);(73,8);(73,69);(83,35);(94,15);(120,0);(139,
5);(158,20);(134,120);(113,110);(100,116);(89,132);(82,179);(79,254);(79,378);(0
,378);(0,8)}}
{\sp{\sn pSegmentInfo}{\sv 2;35;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}

{\shp {\*\shpinst\shpleft2520\shptop7630\shpright2755\shpbottom8020\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz688\shplid46
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 235}}{\sp{\sn geoBottom}{\sv 390}}
{\sp{\sn pVerticies}{\sv 8;24;(235,230);(80,230);(90,280);(120,305);(140,295);(1
55,270);(230,285);(190,365);(115,390);(55,370);(15,300);(0,195);(30,55);(115,0);
(180,25);(220,95);(235,215);(235,230);(155,160);(145,100);(120,85);(90,110);(80,
160);(155,160)}}
{\sp{\sn pSegmentInfo}{\sv 2;50;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 203958
6}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft2518\shptop7633\shpright2751\shpbottom8020\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz715\shplid47
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 233}}{\sp{\sn geoBottom}{\sv 387}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;29;(233,228);(79,228);(88,279);(102,297);(118,303);(1
39,293);(153,270);(229,282);(212,330);(188,363);(158,381);(117,387);(81,381);(54
,366);(33,339);(17,299);(5,251);(0,194);(9,114);(32,53);(68,12);(114,0);(153,6);
(182,24);(204,53);(220,93);(229,146);(233,212);(233,228)}}
{\sp{\sn pSegmentInfo}{\sv 2;59;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft2597\shptop7717\shpright2672\shpbottom7792\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz715\shplid48
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 75}}{\sp{\sn geoBottom}{\sv 75}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;10;(75,75);(73,41);(65,17);(53,3);(38,0);(21,6);(9,26
);(0,75);(75,75);(75,75)}}
{\sp{\sn pSegmentInfo}{\sv 2;21;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft3460\shptop5210\shpright5190\shpbottom6795\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz722\shplid49
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1730}}{\sp{\sn geoBottom}{\sv 1585}}
{\sp{\sn pVerticies}{\sv 8;25;(865,0);(690,15);(530,60);(255,230);(70,485);(20,6
30);(0,790);(20,950);(70,1100);(255,1350);(530,1525);(690,1570);(865,1585);(1040
,1570);(1205,1525);(1480,1350);(1660,1100);(1715,950);(1730,790);(1715,630);(166
0,485);(1480,230);(1205,60);(1040,15);(865,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;52;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;2457
7;32768}}

{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 159871

85}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft3460\shptop5211\shpright5188\shpbottom6795\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz731\shplid50
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 1728}}{\sp{\sn geoBottom}{\sv 1584}}{\sp{\sn shapePath}{\sv 4}
}
{\sp{\sn pVerticies}{\sv 8;37;(864,0);(690,16);(528,63);(381,135);(253,232);(147
,349);(67,484);(18,633);(5,711);(0,792);(5,873);(18,952);(67,1101);(147,1234);(2
53,1351);(381,1449);(528,1522);(690,1567);(864,1584);(1038,1567);(1200,1522);(13
47,1449);(1475,1351);(1581,1234);(1660,1101);(1710,952);(1723,873);(1728,792);(1
723,711);(1710,633);(1660,484);(1581,349);(1475,232);(1347,135);(1200,63);(1038,
16);(864,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;75;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft3856\shptop6348\shpright4791\shpbottom6495\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz731\shplid51
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 935}}{\sp{\sn geoBottom}{\sv 147}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;9;(0,0);(117,64);(234,111);(351,138);(468,147);(584,1
38);(701,111);(818,64);(935,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;19;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft3960\shptop5680\shpright4140\shpbottom5845\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz738\shplid52
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 180}}{\sp{\sn geoBottom}{\sv 165}}
{\sp{\sn pVerticies}{\sv 8;9;(90,0);(25,25);(0,85);(25,140);(90,165);(155,140);(
180,85);(155,25);(90,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 135528
41}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft3958\shptop5683\shpright4137\shpbottom5848\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz745\shplid53
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 179}}{\sp{\sn geoBottom}{\sv 165}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;17;(89,0);(54,6);(26,24);(8,51);(0,84);(8,116);(26,14
1);(54,159);(89,165);(125,159);(153,141);(171,116);(179,84);(171,51);(153,24);(1
25,6);(89,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;35;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45

824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft4515\shptop5680\shpright4690\shpbottom5845\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz751\shplid54
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 175}}{\sp{\sn geoBottom}{\sv 165}}
{\sp{\sn pVerticies}{\sv 8;9;(90,0);(25,25);(0,85);(25,140);(90,165);(150,140);(
175,85);(150,25);(90,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;20;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;24577;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 135528
41}}{\sp{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv
1}}{\sp{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft4512\shptop5683\shpright4690\shpbottom5848\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz758\shplid55
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 178}}{\sp{\sn geoBottom}{\sv 165}}{\sp{\sn shapePath}{\sv 4}}
{\sp{\sn pVerticies}{\sv 8;17;(88,0);(54,6);(25,24);(7,51);(0,84);(7,116);(25,14
1);(54,159);(88,165);(124,159);(153,141);(171,116);(178,84);(171,51);(153,24);(1
24,6);(88,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;35;16384;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45824;1;45
824;1;45824;32768}}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 0}}{\sp{\sn lineWidth}{\sv 14631}
}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\sp{\sn fBehindDocume
nt}{\sv 1}}{\sp{\sn lineColor}{\sv 2039586}}
}}
{\shp {\*\shpinst\shpleft1286\shptop1137\shpright7503\shpbottom1157\shpfhdr0\shp
bxpage\shpbypage\shpwr3\shpwrk0\shpfblwtxt1\shpz770\shplid56
{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 6217}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(0,20);(6217,20);(6217,0);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
}
{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\landscape\paperw13020\paperh8700\pard\sb0\sl-240{\bk
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ql\li6542\sb0\sl-207\slmult0 \par\pard\ql\li6542\sb0\sl-207\slmult0 \par\pard\ql
\li6542\sb0\sl-207\slmult0 \par\pard\ql\li6542\sb0\sl-207\slmult0 \par\pard\ql\l
i6542\sb0\sl-207\slmult0 \par\pard\ql\li6542\sb67\sl-207\slmult0 \up0 \expndtw-8
\charscalex94 \ul0\nosupersub\cf5\f6\fs18 Table 9.2 \par\pard\li1955\sb82\sl-207
\slmult0\fi3612 \up0 \expndtw-5\charscalex100 Manual Communication Systems\par\p
ard\li1955\sb131\sl-207\slmult0\fi0 \up0 \expndtw-5\charscalex100 Advantages\par
\pard\sect\sectd\sbknone\cols2\colno1\colw6856\colsr160\colno2\colw5864\colsr160
\ql \li1955\sb80\sl-207\slmult0 \up0 \expndtw-8\charscalex92 Manual systems can
be made portable and lightweight.\par\pard\qj \li1955\sb0\sl-219\slmult0 \par\pa
rd\qj \li1955\ri547\sb3\sl-219\slmult0\tx2115 \up0 \expndtw-8\charscalex94 Manua
l systems can contain one or a combination of symbol \line\tab \up0 \expndtw-8\c
harscalex89 sets (e.g., symbols, photos, or objects).\par\pard\qj \li1955\sb0\sl
-218\slmult0 \par\pard\qj \li1955\ri1169\sb1\sl-218\slmult0\tx2115 \up0 \expndtw

-8\charscalex92 Manual systems can contain vocabulary items in any \line\tab \up
0 \expndtw-8\charscalex89 language.\par\pard\qj \li1955\ri548\sb3\sl-218\slmult0
\tx2115 \up0 \expndtw-8\charscalex91 Manual systems can be created using any siz
e of symbols and \line\tab \up0 \expndtw-7\charscalex100 symbol grid.\par\pard\q
j \li1955\ri548\sb1\sl-219\slmult0\tx2115 \up0 \expndtw-8\charscalex91 Manual sy
stems can be used in all environments (e.g., pool or \line\tab \up0 \expndtw-8\c
harscalex94 bathtub).\par\pard\qj \li1955\ri549\sb0\sl-219\slmult0\tx2115\tx2115
\up0 \expndtw-8\charscalex93 Manual systems are typically more dependable: repa
irs (e.g., \line\tab \up0 \expndtw-8\charscalex91 recontacting or regluing) are
usually easier and quicker than \line \tab \up0 \expndtw-8\charscalex93 with ele
ctronic systems.\par\pard\qj \li1955\ri548\sb0\sl-218\slmult0\tx2115 \up0 \expnd
tw-8\charscalex93 Manual systems typically do not need to be charged or main-\li
ne \tab \up0 \expndtw-8\charscalex89 tained as regularly as electronic systems.\
par\pard\ql \li1955\sb12\sl-207\slmult0 \up0 \expndtw-8\charscalex89 Manual syst
ems usually require less set up.\par\pard\qj \li1955\ri549\sb3\sl-218\slmult0\tx
2115 \up0 \expndtw-8\charscalex93 Families of individuals using AAC appear to ha
ve less fear of \line\tab \up0 \expndtw-8\charscalex90 manual systems than of el
ectronic systems.\par\pard\qj \li1955\ri548\sb0\sl-219\slmult0\tx2115 \up0 \expn
dtw-8\charscalex96 Families of individuals using AAC are typically less horrifie
d \line\tab \up0 \expndtw-8\charscalex92 when a manual system is lost or broken.
\par\pard\column \ql \li20\sb80\sl-207\slmult0 \up0 \expndtw-8\charscalex94 Manu
al systems require m\par\pard\qj \li20\ri3783\sb3\sl-219\slmult0\fi159\tx190 \up
0 \expndtw-8\charscalex90 ner (e.g., the listener need \up0 \expndtw-8\charscale
x94 With a manual system, if the \line\tab \up0 \expndtw-8\charscalex95 cation d
epends on his o\par\pard\ql \li180\sb9\sl-207\slmult0 \up0 \expndtw-8\charscalex
94 tions.\par\pard\qj \li20\ri3955\sb3\sl-218\slmult0\tx190 \up0 \expndtw-8\char
scalex88 Because manual systems d \line\tab \up0 \expndtw-8\charscalex94 in grou
p settings.\par\pard\qj \li20\ri3843\sb2\sl-219\slmult0\fi0\tx190\tx190 \up0 \ex
pndtw-8\charscalex95 Many people unfortunatel \line\tab \up0 \expndtw-8\charscal
ex90 \ul0\nosupersub\cf10\f11\fs18 \u8216?\u8216?\ul0\nosupersub\cf5\f6\fs18 com
munication\ul0\nosupersub\cf10\f11\fs18 \u8217?\u8217?\ul0\nosupersub\cf5\f6\fs1
8 because \line \up0 \expndtw-8\charscalex96 Many people unfortunatel \line\tab
\up0 \expndtw-8\charscalex89 use of manual systems.\par\pard\qj \li20\ri3931\sb
0\sl-219\slmult0\tx190\tx190 \up0 \expndtw-8\charscalex95 With manual systems, t
he \line\tab \up0 \expndtw-8\charscalex100 the larger the communi \line \tab \up
0 \expndtw-8\charscalex92 must manually change o
{\shp {\*\shpinst\shpleft1955\shptop2108\shpright11798\shpbottom2128\shpfhdr0\sh
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{\sp{\sn fFillOK}{\sv 1}}{\sp{\sn fFilled}{\sv 1}}{\sp{\sn fillColor}{\sv 0}}{\s
p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft1955\shptop7160\shpright11798\shpbottom7180\shpfhdr0\sh
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
\sn geoRight}{\sv 9843}}{\sp{\sn geoBottom}{\sv 20}}
{\sp{\sn pVerticies}{\sv 8;4;(9843,0);(9843,20);(0,20);(0,0)}}
{\sp{\sn pSegmentInfo}{\sv 2;10;16384;45824;1;45824;1;45824;1;45824;24577;32768}
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}

{\shp {\*\shpinst\shpleft1955\shptop2406\shpright7016\shpbottom2426\shpfhdr0\shp
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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{\sp{\sn pVerticies}{\sv 8;4;(0,20);(5061,20);(5061,0);(0,0)}}
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p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}
{\shp {\*\shpinst\shpleft7016\shptop2406\shpright11798\shpbottom2426\shpfhdr0\sh
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{\sp{\sn shapeType}{\sv 0}}{\sp{\sn fFlipH}{\sv 0}}{\sp{\sn fFlipV}{\sv 0}}{\sp{
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p{\sn fLine}{\sv 0}}{\sp{\sn lineType}{\sv 0}}{\sp{\sn fArrowheadsOK}{\sv 1}}{\s
p{\sn fBehindDocument}{\sv 1}}{\sp{\sn lineColor}{\sv 0}}
}}\par\pard\sect\sectd\fs24\paperw8700\paperh13020\pard\sb0\sl-240{\bkmkstart Pg
253}{\bkmkend Pg253}\par\pard\li2721\sb0\sl-241\slmult0\par\pard\li2721\sb0\sl-2
41\slmult0\par\pard\li2721\sb201\sl-241\slmult0\fi0\tx7197 \up0 \expndtw-8\chars
calex95 \ul0\nosupersub\cf5\f6\fs18 Augmentative and Alternative Communication\t
ab \up0 \expndtw-10\charscalex95 \ul0\nosupersub\cf2\f3\fs22 233\par\pard\ql \li
2502\sb0\sl-207\slmult0 \par\pard\ql\li2502\sb139\sl-207\slmult0 \up0 \expndtw0\
charscalex102 \ul0\nosupersub\cf7\f8\fs24 E\ul0\nosupersub\cf31\f32\fs17 LECTRON
IC\ul0\nosupersub\cf7\f8\fs24 C\ul0\nosupersub\cf31\f32\fs17 OMMUNICATION\ul0\n
osupersub\cf7\f8\fs24 S\ul0\nosupersub\cf31\f32\fs17 YSTEMS \par\pard\qj \li128
6\ri961\sb250\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex93 \ul0\nosupersub
\cf2\f3\fs22 Electronic communication systems require a battery to operate.
\up0 \expndtw-9\charscalex96 They come in all sizes and shapes with dierent feat
ures that will assist \up0 \expndtw-8\charscalex100 the AAC user to communicate
eectively. Electronic communication \up0 \expndtw-10\charscalex96 devices range
from simplistic (single message voice output device) to \up0 \expndtw-10\charsc
alex90 complex (multimessage or multiaccess device). \par\pard\qj \li1286\ri959\
sb2\sl-258\slmult0\fi478 \up0 \expndtw-10\charscalex94 As with manual communi
cation systems, vocabulary items on \line \up0 \expndtw-9\charscalex98 elect
ronic communication devices can be selected directly or \line \up0
\expndtw-9\charscalex98 indirectly. Direct access consists of pointing with a b
ody part or use of \line \up0 \expndtw-6\charscalex100 a pointer, indicators,
a joystick, or an emulated mouse. Some \line \up0 \expndtw-9\charscalex94
electronic devices have a touch screen that closely resembles the touch \line \
up0 \expndtw-9\charscalex100 window for computers, automated teller machine
s, or MetroCard \line \up0 \expndtw-10\charscalex94 vending machines. W|th a l
ight touch, the AAC user can access any cell \line \up0 \expndtw-9\charscalex97
on the screen or display of the communication device. Electronic \line
\up0 \expndtw-9\charscalex100 devices with touch screens have modications to allo
w the user ease \line \up0 \expndtw-9\charscalex96 of access to suit his or
her physical status. One modication will \line \up0 \expndtw-9\charscalex9
4 allow the user to slide his or her hand across the screen, making
\line \up0 \expndtw-9\charscalex97 no selection until he or she lifts the hand o
the desired location or cell \line \up0 \expndtw-9\charscalex93 on the screen.
Keyguards may be needed to improve the accuracy \line \up0 \expndtw-9\c
harscalex92 of vocabulary selections. Electronic communication systems can
also \line \up0 \expndtw-9\charscalex91 be accessed indirectly through a switc
h using scanning (see earlier section \line \up0 \expndtw-6\charscalex100 on in

direct selection or scanning for various scanning options). \line \up0 \e

xpndtw-10\charscalex96 Some electronic devices have only one means of ac
cess \up0 \expndtw-10\charscalex94 (direct \par\pard\qj \li1286\ri959\sb1\sl-260
\slmult0 \up0 \expndtw-10\charscalex93 selection or scanning), whereas others ca
n be accessed in various ways \line \up0 \expndtw-9\charscalex94 (i.e., both d
irect selection and scanning or point, joystick, emulated \line \up0 \exp
ndtw-8\charscalex100 mouse, and single switch scanning). Electronic device
s that can \line \up0 \expndtw-8\charscalex100 be accessed in two or more ways
are said to have multiaccess input \line \up0 \expndtw-10\charscalex90 methods.
\par\pard\qj \li1286\ri960\sb0\sl-260\slmult0\fi478 \up0 \expndtw-10\charscalex
93 There are many advantages and disadvantages to electronic com-\line \up0 \exp
ndtw-9\charscalex100 munication systems. Some of them are listed in Table 9.3.
Electronic \line \up0 \expndtw-10\charscalex94 communication systems have variou
s features that dier among devices \line \up0 \expndtw-10\charscalex95 to better
match the specic needs and skills of the AAC user. Features \line \up0 \expndtw-9
\charscalex98 include, but are not limited to, type of display, output upon voca
bulary \line \up0 \expndtw-9\charscalex91 selection, type of electronic device (
dedicated versus nondedicated), avail-\line \up0 \expndtw-9\charscalex96 ability
of environmental control units, and portability. Refer to Table 9.4 \line \up0
\expndtw-9\charscalex93 for a listing of some electronic communications devices
and their specic \line \up0 \expndtw-10\charscalex84 features. \par\pard\ql \li54
45\sb6\sl-253\slmult0 \up0 \expndtw-10\charscalex79 Text continues on page 272
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}}\par\pard\sect\sectd\fs24\landscape\paperw13020\paperh8700\pard\sb0\sl-240{\bk
mkstart Pg254}{\bkmkend Pg254}\par\pard\ql \li6548\sb0\sl-207\slmult0 \par\pard\
ql\li6548\sb0\sl-207\slmult0 \par\pard\ql\li6548\sb0\sl-207\slmult0 \par\pard\ql
\li6548\sb188\sl-207\slmult0 \up0 \expndtw-8\charscalex93 \ul0\nosupersub\cf5\f6
\fs18 Table 9.3 \par\pard\li1950\sb74\sl-207\slmult0\fi3515 \up0 \expndtw-5\char
scalex100 Electronic Communication Systems\par\pard\li1950\sb131\sl-207\slmult0\
fi0 \up0 \expndtw-5\charscalex100 Advantages\par\pard\sect\sectd\sbknone\cols2\c
olno1\colw6771\colsr160\colno2\colw5949\colsr160\ql \li1950\sb79\sl-207\slmult0
\up0 \expndtw-8\charscalex93 With the use of electronic systems, the communicati
on partner\par\pard\ql \li1950\ri69\sb4\sl-219\slmult0\fi179\tx2129\tx2129\tx212
9\tx2129\tx2129 \up0 \expndtw-8\charscalex91 does not have to assist the user in
communication, therefore \line\tab \up0 \expndtw-8\charscalex95 allowing the AA
C user to communicate independently. \line \up0 \expndtw-8\charscalex94 The voic
e output feature that is included in many electronic \line\tab \up0 \expndtw-8\c
harscalex94 systems allows independent communication in all environments \line \
tab \up0 \expndtw-8\charscalex95 (e.g., talking on the phone or talking in group
settings). \line \up0 \expndtw-8\charscalex91 Electronic systems usually allow
various access methods: direct \line\tab \up0 \expndtw-8\charscalex89 selection
and scanning (multiple access methods are essential \line \tab \up0 \expndtw-8\c
harscalex92 for those with progressive disorders).\par\pard\qj \li1950\ri278\sb1
\sl-218\slmult0\tx2129 \up0 \expndtw-8\charscalex89 Some electronic systems have
dynamic displays that allow access \line\tab \up0 \expndtw-8\charscalex94 to a
large amount of vocabulary quickly.\par\pard\ql \li1950\sb0\sl-219\slmult0 \par\
pard\ql \li1950\sb0\sl-219\slmult0 \par\pard\ql \li1950\ri85\sb2\sl-219\slmult0\
fi0\tx2129 \up0 \expndtw-8\charscalex90 Some electronic systems contain preprogr
ammed pages that enable \line\tab \up0 \expndtw-8\charscalex91 the AAC user to h
ave access to a range of vocabulary quickly. \line \up0 \expndtw-8\charscalex95

Electronic systems that contain digitized voice output allow\par\pard\ql \li2129

\sb10\sl-207\slmult0 \up0 \expndtw-8\charscalex92 any language to be programmed.
\par\pard\qj \li1950\ri306\sb3\sl-219\slmult0\tx2129\tx2129 \up0 \expndtw-8\char
scalex92 Electronic systems that are contained in a computer provide the \line\t
ab \up0 \expndtw-8\charscalex96 AAC user with both communication and computer ac
tivities \line \tab \up0 \expndtw-8\charscalex89 (i.e., educational software and
Internet access).\par\pard\ql \li1950\ri215\sb0\sl-219\slmult0\tx2129\tx2129 \u
p0 \expndtw-8\charscalex93 Some electronic systems may contain environmental con
trol \line\tab \up0 \expndtw-8\charscalex93 units that allow the AAC user to acc
ess his or her environment \line \tab \up0 \expndtw-8\charscalex94 and to commun
icate.\par\pard\qj \li1950\ri16\sb0\sl-219\slmult0\tx2129 \up0 \expndtw-8\charsc
alex92 Some electronic systems may contain auditory prompts that enable \line\ta
b \up0 \expndtw-8\charscalex93 or aid visually impaired and cognitively impaired
users who scan.\par\pard\column \ql \li20\sb79\sl-207\slmult0 \up0 \expndtw-8\c
harscalex93 With electronic systems, the\par\pard\ql \li201\sb13\sl-207\slmult0
\up0 \expndtw-8\charscalex89 the display or screen.\par\pard\qj \li6931\sb0\sl-2
18\slmult0 \par\pard\qj \li20\ri3833\sb3\sl-218\slmult0\tx211 \up0 \expndtw-8\ch
arscalex90 Some electronic systems con \line\tab \up0 \expndtw-8\charscalex93 th
erefore, there is little abil\par\pard\qj \li6931\sb0\sl-218\slmult0 \par\pard\q
j \li20\ri3796\sb4\sl-218\slmult0\tx211 \up0 \expndtw-7\charscalex100 A limited
number of electron \line\tab \up0 \expndtw-8\charscalex92 photographs, and when
the\par\pard\qj \li6931\sb0\sl-219\slmult0 \par\pard\qj \li20\ri3801\sb2\sl-219\
slmult0\tx211\tx211 \up0 \expndtw-8\charscalex95 Usually the more vocabulary \li
ne\tab \up0 \expndtw-8\charscalex93 smaller symbols or using \line \tab \up0 \ex
pndtw-8\charscalex90 screen, which is often a hea\par\pard\ql \li20\ri3781\sb1\s
l-218\slmult0\fi180\tx211 \up0 \expndtw-8\charscalex93 the ambulatory user (excl
u \line \up0 \expndtw-8\charscalex93 With electronic systems tha \line\tab \up0
\expndtw-8\charscalex96 a limited number of langua\par\pard\qj \li20\ri3951\sb3\
sl-218\slmult0\tx210 \up0 \expndtw-8\charscalex93 With electronic systems tha \l
ine\tab \up0 \expndtw-7\charscalex100 time is limited.\par\pard\ql \li20\ri3679\
sb1\sl-219\slmult0\tx210\tx210 \up0 \expndtw-8\charscalex92 Electronic systems r
equire m \line\tab \up0 \expndtw-8\charscalex90 cost of batteries) and repairs \
line \tab \up0 \expndtw-8\charscalex94 that leave the AAC user with\par\pard\qj
\li20\ri3849\sb0\sl-219\slmult0\tx210\tx210 \up0 \expndtw-8\charscalex90 The use
of electronic systems \line\tab \up0 \expndtw-8\charscalex93 (e.g., one would n
ot use it \line \tab \up0 \expndtw-8\charscalex94 with dynamic displays can\par\
pard\ql \li20\sb10\sl-207\slmult0 \up0 \expndtw-8\charscalex94 Electronic system
s typically\par\pard\qj \li6931\sb0\sl-218\slmult0 \par\pard\qj \li20\ri3874\sb5
\sl-218\slmult0\tx210 \up0 \expndtw-8\charscalex90 Some families have a fear of
\line\tab \up0 \expndtw-8\charscalex97 may not provide the AAC
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}}
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}}\par\pard\sect\sectd\fs24\landscape\paperw13020\paperh8700{\shp
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