ELF – Early Listening Function
Contents
1. Mommy singing a song i e Mary had a Little Lamb Clapping hands together in quiet applause Daddy saying ship ship ship in normal voice loudness Daddy says shoe buh shoe buh in loud voice Loud door knock with knuckles Hold 2 spoons together back to back by their ends and hit them hard on your palm twice Hitting a frying pan or pot with a wooden or metal spoon 6 ins Listening activities at different distances 3 ft Closest distance Next child responded room in noise 6 ft 10 ft 15 feet none gt 6 ft 15 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function ELF Checklist v Parents Response Form Infant amp Young Child Amplification Use Checklist POP PO OHSS LEE EH EEEE EE OEEEH SELES TEEEETOSEHE TE SOEEE EE EEEOE ESO OEE TH EEEO EE SEEEEEOEEEE EE SEOEE EE EOOE EE EOOE THOSE ESTO OHESEEEE TET OEETE SOTO E EEO ETOEEEEHTEEEEESEEEE HE EEOHETHEOEEEEEEEELEEEEEEEELEEEEELEEEEEECEEDOD POPP O eH O SEE ERE EOEEE EE EEOEHEEHOEEEEEEEEEEEOOE THO EEE EE EOEETESEEEHETEEHEEEOEEEE HOLE E EE ETEEEEEEEEEEEOEEEHEEEOEE EE HEEEHETEOEEETOLEE HELO ETE LEEEO LE EEEELSELEEEEEEEEELELELELELELEELOEEEE BO LSEL EE LEEEE ELE EEEEe Parents please complete this form each time your child uses new hearing aids hearing aid set tings features programs or other amplification devices like FM systems or a cochlear implant map Amplification devices are set pre2. between baby and speaker is beyond feet Trial of hearing aid s type or special features Trial or continued use of hearing aid s type or special features Improvement noted due to early auditory development or progress in auditory skills Potential cochlear implant user suggest parents contact implant team for more information Potential user for an FM system due to difficulties listening in noise and to speech at a distance Parent or caregiver has demonstrated willingness to use FM during the child s waking hours Hours use throughout the day __ Pe LE LI EF LE Ue uu 21 Written by Karen Anderson 2002 Design by Oticon 2007 People First We believe that it takes more than technology and audiology to create the best hearing instruments That s why we put the individual needs and wishes of people with hearing loss first in our development of new hearing care solutions www oticonusa com Www oticon ca oticon PEOPLE FIRST 910 15 911 00 09 07 Printed in Denmerk
3. hearing or is fit with amplification instruments Count and multiply responses on the ELF parent response form to obtain weighted scores for quiet listening and bonus listening in noise points Listening in Quiet Count the number of Y s and M s for each distance If both are present only transfer the number of Y s Listening in Noise Transfer the amount of responses where the child responded at a distance gt 6 ft Step 1 Transfer numbers from Parent Response Form Step 2 Multiply by weight factor 19 Written by Karen Anderson 2002 Design by Oticon 2007 PEs iL ij ELF Early Listening Function Date s No of Multiply No of Multiply Yes X3 Maybe x1 Typical Loud Responses noted Responses noted Multiply x 15 Multiply x 10 Hearing Status New diagnosis new amplification parent detected possible ear infection check auditory development etc 20 Written by Karen Anderson 2002 Design by Oticon 2007 Hearing Loss Management Considerations Discussed by audiologist interventionist Size of listening bubble proximity for communication in quiet needs to be at distance or closer when no amplification is used Size of the listening bubble proximity for communication in quiet needs to be at distance or closer when amplification is worn consistently Control of background noise needed when communicating especially when distance
4. observation by the parents and daily caregivers of the child useful information can be gathered that can develop confidence in the 3 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function optimal adjustment of the hearing instruments for daily use The ELF can also be useful in determining if a per sonal FM system would be of benefit as the ELF activities raise the aware ness of the parents about the daily situations and listening conditions would benefit from FM system use The ELF can also be used as a pretest and posttest for comparing hearing instruments or FM system benefit 3 Tracking improvements in auditory development Understanding the effect of hearing loss on communication access in daily situation by the parents and Caregivers can only support the even tual communication outcomes of the child with hearing loss Development of verbal language depends on con sistent communication access For parents that choose an auditoryoral or auditory verbal communication op tion for their child a strong focus on auditory development is necessary Like any other developing part of the body the auditory system de velops as itis stimulated consistently over time The ELF can assist parents and early interventionists in tracking a child s functional use of early audi tory skills in the home Recognizing the importance of proximity to the child during communication and how the li
5. quieting of random or intentional movements 3 starting to suck or initation of limb movements if the infant had been relatively still Infants older than 6 months will have clearer responses to sound and the use of the ELF listening activities by the parents may be more successful then For children with normal hearing ru dimentary headturns can be expected at a developmental age of 5 months only on a lateral plane and a listen ing attitude may be present includ ing more interest in quiet voices Developmentally at 7 9 months the baby begins to be highly responsive to quiet voices and may localize to the side and indirectly below to either side At 9 13 months of age to either side localization includes indirectly above At 13 16 months developmen tal age and beyond localization to the sides below and above is an expected response The ELF is just one of the many tools and techniques available to elicit impressions about a young child s hearing ability It is not intended to be a diagnostic tool or a formal screening measure to detect hearing impairment or replace appropriate Real Ear to Coupler Difference ampli fication verification techniques The ELF is intended to involve the parents or caregivers of a child with identified hearing loss in gathering information on how the young child is able to use his or her hearing ability under contrived listening situations in their environment Written by
6. Function ELF Early Listening Function Discovery tool for parents and caregivers of infants and toddlers POPPE SLO EE EOE EEE EE LEEEHEOEEEEHOLOEE ET OEETEHEOEEEE HOSE ESEOEEE HOLE EE ET OTETE HELE EEELELEL ELE OEEDELELESLEELEEEELEOEEEDOLES POCO SESE EEE ES EEEEEEEEEE TE OEE ES EEEEETEEOEEEEEEEEEEOEEEH ETOH EEOOEE EH TEEEE EE ESEEHEEEDEE ESE EEELEEELEEEEEOEEE OLE OEE EEO OS You will be watching how your child responds to 12 listening activities you will present in your home or wherever the child is much of his or her waking hours 2 Children who are alert but not fussy are in the best state to respond to sound These responses can be very subtle Most of the time the child will only respond once or twice to the sound and then will not pay attention again for awhile It may take observing your child over the course of a week before you have presented the sounds enough times to feel fairly certain about your child s capability to respond Pee e eres eccccsseccesesecereseereseseLereZeLerEeseoeEeeELEEDEZELELEEEEEEEELEOH EDO OEEEDOe Pee e ee eeeeeereeeereseserereseeEeEeseLELeEEEEERELELEE ELE LEEEEEEEEEEELEEEE ELE EE ELLE EEEOLS Loud sounds can cause adverse respons es or discomfort In extreme cases a very loud sound could harm hearing There fore it is important to not present the loud sounds close to your baby unless you have observed no responses to quieter sounds at near distances Watch for responses in noise onl
7. Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function f 8 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function ELF Early Listening Function Discovery tool for parents and caregivers of infants and toddlers Why Hearing is a distance sense anda child with a hearing loss will have a reduced hearing range or a smaller listening bubble than a child with normal hearing When you hear your young child fuss in the crib or bed when you are in another room you Mooo Mooo are using your hearing range In other words you have a listening bubble that includes hearing sounds of that loudness and at that distance People with hearing loss have smaller listen ing bubbles How well young children with hearing loss function varies between individuals and typically The size of a child s listening bubble is based on his or her degree of hearing loss and consistent daily use of amplification 9 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function shows some improvement with listen ing experience Audiologists test to find out what tones or pitches of sound from low to high a child can detect Only someone who is with the child for hours everyday can observe how the child is using his her hearing ability in every day situations Babies can react to sounds even while in the womb so no child is too
8. Oticon Pediatrics Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function Discovery tool for parents and caregivers of infants and toddlers 4 months to 3 years PEOPLE FIRST ELF Early Listening Function This manual is for pediatric audiologists and early intervention service providers who are working with families of infants and toddlers with hearing impairment The Early Listening Function instrument has been designed to obtain an indication of the functional use of hearing in very young children 2 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function The ELF has three primary purposes 1 Parent involvement and empowerment With universal newborn hearing screening infants with hearing loss are being identified in the first month of life and parents are typically not prepared for the diagnosis of hearing loss in their newborn The adjustment to having a child with hearing loss and the eventual acceptance of the hearing loss as an integral feature of the child s life comes with the understanding of how the hearing loss may affect the child Gaining the parents involvement and participa tion in the discovery process of how the child functions auditorily can be very beneficial to the adjustment and acceptance process of the parents It also establishes a partnership between the parents and audiologist as the te
9. am who identifies the child s hearing abilities and current limita tions and growth change over time Through this participation parents are empowered to be involved in observing their child s hearing be havior This can then lead to a deeper appreciation of the nature of commu nication and to readiness to become informed about effective parent child interaction strategies and techniques to facilitate auditory development For children with mild or unilateral hearing loss the ELF can assist the parents in recognizing the limita tions of the hearing loss which may motivate them to consider amplifica tion use seriously Children with the best language outcomes are those who have parents that are intimately involved in all areas of early interven tion and hearing loss management As the child s pediatric audiologist you have entered into a partnership to manage the child s hearing needs as they grow and develop throughout childhood 2 Estimating amplification benefit Although diagnostic procedures are improving for young infants there remains a degree of uncertainty about the exact hearing thresholds of most infants at the time they are fit with their first hearing instruments The range of technologies available to au diologists to choose from when fitting young children has also increased Real Ear to Coupler Difference RECD measures provide targets for hear ing aid fitting With involvement and careful
10. arents about the dangers of loud sounds on hearing and comfort Expected Responses Young children respond best to voices especially the voices of their par ents Developmentally newborns and children with normal hearing who are under 5 months of age do not respond to very low intensity sounds 6 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function The quiet listening activities listed may produce no response beyond six inches or three feet especially if a moderate hearing loss or greater is present Reassure the parents to not be con cerned about these quiet activities un til the child is at least 4 5 months old Reinforce that the baby needs to be quiet and content Even when in the most receptive state a baby may only respond once or twice to the listening activity It is expected that the ELF will take a concerted effort over a period of days to complete If there is an audi ology appointment scheduled in two weeks urge the parents to complete as much of it as possible Their level of participation can provide insights into their state of grieving or real life priorities in the family Model for the parent or describe what to look for in the young infant s responses The following responses are some of the easier behaviors to observe 1 Moro response or startle reaction resulting in a full body jerk 2 cessation of activity stopping movement cessation of sucking
11. cisely however some minor adjustments may be needed for optimal listening ability Your observations can assist in determining improvements how well this amplification is meeting your child s listening needs in his or her every day environ ments Complete these items approximately 4 to 10 days after your child begins to listen with the new or newly adjusted amplification If possible ask your child s other caregivers and the early intervention specialist that works with your family about what changes they observe Share the completed form with the audiologist and be sure to discuss any questions you may have about the child s hearing or use of the amplification instrument Describe current amplification used new settings etc 16 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function A listening check of the amplification instruments is typically performed by an adult times per day or week e g battery check listening with stethoset watching for child responses to m aw 00 ee sh s t sounds checking settings earmold fit etc Are parents caregivers comfortable using the amplification system very mostly somewhat not really no Are parents caregivers comfortable with how to check and maintain very mostly somewhat notreally no On a typical day my child wears amplification waking hours Describe specific situations when you noticed improvements in listenin
12. ctually damage hearing Therefore introduce the loud sounds at 15 and 10 feet first Do not produce a loud sound hitting a frying pan close to your young child unless you see no response to the quieter listening activities or no response to the loud sounds at the farthest distances You will need to try to get two or more reactions to sound for each activity to be sure that the child was actually reacting to sound and didn t just happen to move for any of a number of reasons other than noticing the sound you just made Babies in their first couple of months can seem com pletely unaware to sound even when they have some hearing Children with hearing loss are often very aware of other sensory input such as visual movements motion or tactile vibrations feeling When you are doing the listening activities you need to be sure that you are behind the child so that your baby cannot see you Be sure your shadow is not visible or your breath or other vibra tions are not felt by the child causing a reaction rather than the response being a specific auditory response Doing the listening activities within six inches to three feet of your child will be the trickiest Try to be consist ent about how loud you make the noises as you present them at differ ent distances Your opinion based on watching your child respond to sound is important 12 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening
13. e or profound degree of hearing loss may have few responses even to the loud sounds Put a Yin the box meaning YES if you have observed the child responding to the specified listening activities most of the time e g 4 of 5 times Put an M in the box meaning MAYBE if you have observed the child responding to some sounds but only about half of the time e g 2 or 3 of 5 times Put an N in the box meaning NO if you have observed no sure re sponses to the listening activity O Ifyou know your child responds to the quiet sounds put a Y in the box for the louder sounds If he or she responded to the distant sounds for an activity assume the child will respond to those sounds when near If you know your child was unable to respond to the loud sounds putan N in the box for the quieter sounds If the child did not respond to near sounds assume that he or she will not respond to far sounds 14 Written by Karen Anderson 2002 Design by Oticon 2007 a 7 Typical Loudness Activities Quiet Activities Loud Activities Listening Activities Sheet Parents Response Form Based on the child s responses to sound place Y Yes M Maybe or N No in the boxes below 10 le 12 Mommy saying sh sh quietly Hands together palms rubbing together briskly Quiet clucking tongue Mommy saying buh buh buh quietly Turning water full on kitchen sink bathtub
14. er louder to obtain a response at 6 feet Only if the child responded more than once out of several presentations at 6 feet would the parent mark the response as a maybe A radio set on a talk station or the television on in the background would be appropriate when present ing listening activities in noise Try to have this background noise on in the same room or an adjoining room with the door open when presenting the listening activities The point is to see if the child who responds in quiet can also respond when noise is present 5 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function The signal to noise ratio is expected to be typical for the home rather than a calibrated stimulus Responses to the ELF listening activities will be most pronounced for children who have a flat configuration of hearing loss or at least a mild degree of hear ing loss across all speech frequencies Children who have normal hearing through the low frequencies may have robust responses to most or all of the listed ELF listening activities The audiologist or early intervention ist working with the parents must be aware of this potential and may choose to not use the ELF if there is an island of normal or minimal hear ing loss Alternatively the audiolo gist or early interventionist may work with the family to include or replace some of the existing items with high frequency listening activities
15. g ability Not Observed Disagree No change Agree My child appears to 1 Be more aware of my voice 2 1 o 1 2 2 Be more aware of environmental sounds 2 1 o 1 2 3 Search more readily for the location of my voice 2 1 o 1 2 4 Have an increased amount of babbling or talking 2 1 o 1 2 5 Have more interest in communicating 2 1 o 1 2 During ELF listening activities the size of my child s listening bubble 1 Has improved for quiet sounds voices 2 1 o 1 2 2 Has improved for typical sounds and voices 2 1 o 1 2 3 Has improved for loud sounds and voices 2 1 o 1 2 4 Has improved for listening in background noise 2 1 o 1 2 17 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function S 18 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function ELF Score Sheet Professional Response Form G POPP OHO SELES HEEL EEE EOEEE HHS EOE HEHEHE TEEEHETHOEOE EE LOEEOESOEE HE TOOE EET OEEEHOEEOEH OE HOEE EE TOEHETEOEEE HO EEOEHE EO HOEEH ETOH ETOH EEHHOEOE EO LOEEOEHEEEHELTOHE EE OLEEHEEEOEE EE ELEEOEEELEEEDOLEEH EL ELELEEEEELELe Audiologist or Early Interventionist If desired a child s observed responses to ELF listening activities can be converted to a numeric form and compared across time as the child develops auditory skills experiences fluctuating
16. ings going on around him or her Take 5 minutes when the baby seems most responsive to try some of these listening activities There are many different listening situations that we are exposed to everyday It is important to determine your child s ability to respond to sounds under quiet and noisy listening conditions What is meant by quiet is having the television music or radio off picking a time when any other children in the house are doing quiet activities in another part of the living area Look for short calm periods over time in which to administer the quiet activi ties Noise refers to the typical busy household activities such as when the TV is on or children are playing Written by Karen Anderson 2002 Design by Oticon 2007 11 ELF Early Listening Function How The activities were developed with a typical household in mind You will be trying to get an idea of how your child will respond to sound at each distance at first in quiet Then intro duce activities in noise Start with the sounds at 6 inches beginning with the quietest sound and then intro ducing the typical loudness sounds If you know your baby responds readily to an activity at a quiet or typical loudness assume that he or she will also respond when the loud activity is presented at that distance Loud sounds can cause discomfort or an adverse response In some circumstances loud sounds espe cially for long periods over time may a
17. stening bubble may affect the child s responses to auditory stimuli may assist in realistic step by step auditory skills goal setting Although the ELF listening activi ties are detection activities other activities encouraging identification discrimination and comprehen sion of sound can be introduced in the same manner close far quiet typical noisy once the parent has become accustomed to the struc ture of presenting the ELF listening activities Knowing the child s typical auditory behavior can also help the parent in detecting possible changes in hearing status due to otitis media with effusion or hearing loss progres sion Finally hearing loss is invisible and is difficult to explain in a clearly understood manner The structure of the ELF may provide parents a clear and meaningful way to describe their child s hearing impairment to family and friends so that they may respond knowledgably to a comment like I ve seen the baby hear and don t think he needs the hearing aids 4 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function hd Appropriate Use of the ELF Audiologist or early interventionist should discuss these points with parents prior to giving them the ELF The premise of the ELF is to identify if a child is able to detect certain types of sounds from different distances in both quiet and noise Infants like to listen to sounds and voices howe
18. such as e Quiet tsk tsk tsk sound in number 3 rather than quiet clucking tongue e Mommy saing Sss SSS SSS quietly in number 4 rather than buh buh buh e Contrasting a child s responses to a caregiver making the sound ofa duck quacking with the sound of a snake hissing rather than clapping hands together in number 7 only record response for hissing sound e Response to shh shh shh shh rather than ship ship ship in number 8 e Saying sss shh sss shh sss shh rather than shoe buh in number 9 In discussing the activities with the parents if the parents do not feel comfortable with any of the listen ing activities discuss with them what a suitable replacement activity with quiet typical loud or high or low frequency characteristics might be from their own environment The activities should be easy to do and easy to repeat over time For an example of rough use of frequency range buh buh buh is considered a lower frequency speech stimulus and ship ship ship a higher frequency speech stimulus The phrase shoe ba shoe ba shoe ba is considered to have both low and high frequency elements Caution the parents to hit the frying pan or do a loud door knock from a distance first These loud sounds should be presented close to the baby s head only when more distant responses were not observed espe cially when amplification is worn Take the time to warn the p
19. ung infants a change in breathing speed sucking ona bottle and stopping when the sound occurs eye widening or blinking stopping all movement movements of the arms or legs at the onset of the sound or small frowns can all be subtle signs that a 1 4 month old baby heard a sound The baby may do this only once or twice and then even if the sound is heard will probably not respond again for awhile Young children respond best to voices They do not respond to quiet sounds as well as older infants as this skill develops with listening experience Due to this an infant may seem to have more hearing loss at first than he really does This is why it is important to remember that the ELF activities are meant to look at functional responses to sound Start ing at about 5 months the child may purposefully turn in the direction of a sound looking for the sound source People need two ears with the same level of hearing to localize sound If the child does not look for sounds as you would expect there maybe differ ent hearing ability in each ear When All activities should be tried when the baby is settled awake but quietly sucking on a bottle alert and looking at something interesting or playing with soft quiet toys A fussy baby a toddler on the run or a young child who is sleeping is not ready to re spond to sounds You know your child best You are more aware than any one else of when your child responds best to th
20. ver the behavioral response when a 1 month old perceives sound will be somewhat different than an older infant In order for the ELF to provide appropriate results parents need to have a clear idea of what the activities are how to do them and what responses to expect Discuss this information with the parents to prevent their possible frustration or misunderstanding of what they have observed Some parents may need to have their early intervention services provider assist them in doing the ELF listening activities and observing the child s behavior The ELF responses Should be shared with the early inter vention team to enhance the child s program Also discuss with the par ents if they or you will be expected to complete one or both of the ELF score sheets Not all families audiologists or early interventionists will want to track performance over time There fore the audiologist needs to tailor ELF score sheet use for the individual familiy Listening Activities The child must not be able to see the person making the sounds their shadow or be able to detect the sound by feeling their breath air moving or other vibrations These listening activities are not calibrated sounds However it is important that the parent or car egiver attempt to use the same sound intensity during all presentations For example if a child responded toa whisper at 3 feet but not at 6 feet the parent should not make the whisp
21. y after responses in quiet have been observed 4 The favorite and most interesting sound for a baby is the voice of the parents or daily caregivers Finding out how well your voice is heard by the baby is important to know for encouraging the development of auditory and verbal communication skills 13 Written by Karen Anderson 2002 Design by Oticon 2007 2 Even babies with normal hearing who are less than 5 months of age do not respond to quiet sounds Instead they tend to startle at loud noises and may or may not respond to sounds at typical loudness If you do not observe a response to sound keep observing the child as his or her au ditory system develops The ELF listening activities will be easiest for babies to respond to if they are at least a develop mental age of 5 months 6 For most children with hearing loss who are listening in a quiet setting there will be no response to the quiet sounds or distant listening activities especially when no am plification is used Even children with mild or unilateral hearing loss will have some limitations listening to distant sounds or in noise When the typical loudness sounds are presented close it is anticipated that a child with a mild or moderate hearing loss will respond The child may have inconsist ent responses to the distant sounds when no amplification is used and may respond to some quiet sounds with working am plification Children who have a sever
22. young to observe for responses to sound Hearing aids will improve the size of the listening bubble With use of amplification during all waking hours auditory skills will usually improve over time including how well a child is able to use sound for speech and verbal language Buh buh buh Who With another adult try the following activities with your child Infants or young children may react to a new sound only once so you will need to try these different activities overa number of days At least one adult like mom or the daily caregiver should be doing all of these activi ties with the child The helper can be dad the early intervention teacher grandma a neighbor etc Two activi ties ask for mom and dad s voice If it is not possible for a parent to do this a female and male voice should be used If there is no male voice avail able a female voice can be used but the pitch of the voice used should be very low The purpose is to find out if your child responds better to lower or higher pitch sounds The size of a child s listening bubble is based on his or her degree of hearing loss and consistent daily use of amplification 10 Written by Karen Anderson 2002 Design by Oticon 2007 ELF Early Listening Function What As you watch your child s reaction to sound a response may be obvious like startling or jerking the whole body when a louder sound is present or very subtle For yo
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