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Intervention for communication with children with reduced hearing,
who also have autism, is very complex and requires a multi-faceted approach.
We have to make sure to consider those core symptoms of autism.
If a child is having difficulty communicating, there are several different things
that we know about autism that's helpful to think through
in designing our interventions.
For example, we know from the literature that children,
who have an autism spectrum disorder, who are users of technology,
like cochlear implants, show benefits from the use of that technology,
but may not have the same gains as their typically developing peers,
who are using the same intervention. Thinking about autism,
we might want to look further about what we know about autism
and think through: Why is it that they're not showing the same gains,
Are we making sure that they're receiving the kind of interventions,
that are targeting those core symptoms of an autism spectrum disorder,
Are they getting access to ABA
and other interventions to target acquisition of language,
Are we making sure that they're using the devices, if a child has sensory sensitivities
because of their symptoms of autism that are making it uncomfortable
for them to tolerate certain sounds or to have things
on their heads that we're using the strategies that we might use
to desensitize them, so that they're able to benefit from the technology
that's available to them.
Similarly, if a child is having difficulty using sign language expressively,
even though based on their preferences, their family preferences,
and their needs, even though that seems to be what would be most beneficial ideally,
if they're not able to produce signs, then we might think through
what we know about autism in targeting our intervention.
We might look at, "Well gosh, is it that they really have poor imitation skills?",
and we need to take a step back
and think through how we're teaching them to imitate,
whether we're building the motor skills to be able to replicate those signs
so that they can produce them more effectively,
whether we're setting up social situations to reinforce them
for using approximations of signs rather than stopping signing
with a child, when they're not able to produce it themselves initially.
We would not stop talking around hearing children, who has autism
just because they're not speaking. Right?
Similarly in a child who is deaf and hard of hearing,
if they're not able to produce a spoken word
or a sign initially, we're not going to stop providing that feedback
and that communication access in their environment. We want to encourage you
to keep speaking, and keep signing, and keep bathing them in language,
even though there might be more of a delay in their ability to show you,
that they're understanding. You also would think through,
whether we need to build some additional supports here,
if language is a very abstract thing, regardless of the modality,
that isn't making sense to the child,
we might think through ways to make it more concrete to them,
like using some of those picture supports.
Similarly, sometimes we see children, who are communicating in sign language,
who have autism, who are repeating everything that's being signed to them.
You might ask them a question, and they just sign
the same thing that you just signed.
This can be a clue that the child either may not understand
what's being signed to them, or it can be a symptom of autism called echolalia.
Rather than stopping signing, because the child is doing that copying behavior
for either of those reasons, we want to think through including those visual supports,
modeling the language as you want it to be said from their perspective
and working towards expanding their spontaneous communication.
In terms of educational intervention for children, who are deaf and hard of hearing,
who also have autism, this can be extremely challenging and frustrating for families,
because children sometimes need a very specialized type of program.
Unfortunately, we really don't have many settings that were specifically developed
for deaf children, who also have autism.
This means that parents are often finding themselves trying to decide,
"Well, should I put them in the program for children who are deaf and hard of hearing
and hope that they build in some autism supports there,
or should I put them in a program for children, who have autism
and hope that they're getting enough communication support in that environment,
or that we are able to build enough communication support in that environment.
Therefore, we have to really think flexibly about what educational environment
is going to be most appropriate for the child, who's deaf who also has autism.
Again just like in terms of communication and what their needs are for understanding
and using language that can shift over time,
the educational program that's going to be the best fit might also shift over time.
For example, we might see for very young children whose autism symptoms
are making it difficult for them to engage with their environment
and to learn and understand language, an autism program early on
might be appropriate for that child
to help build their engagement with their environment
and their ability for learning and language or their motivation for using language.
Then we might need to shift them into a program that was more initially developed
for children who are deaf and hard of hearing and build some autism supports
in that environment.
This can be challenging depending on what's available in your area,
and the willingness of administrators, parents, and staff to be flexible
in thinking through what kind of program is going to be most appropriate
for the child, who is deaf and hard of hearing.
One thing that might be beneficial is to think outside the box a little bit
about autism intervention for kids, who are deaf and hard of hearing,
especially in areas where it's not possible to find a provider
who's trained in both communicating directly with the child
and autism intervention. You might consider a co-treat models,
where the specialist in autism might work with the child's deafness-related experts
and maybe train the deafness experts on how to use the model
or having experts from the school come to the clinical setting,
where they're working on autism intervention.
Again thinking outside the box for intervention
for children, who have this complex comorbidity could be really beneficial.
We've talked today broadly about a number of different interventions
for treating an autism spectrum disorder, as well, as some unique considerations
in thinking through intervention for children, who are deaf and hard of hearing,
who also have an autism spectrum disorder.
I'm hopeful that you'll look through some of the resources that are available
to you at the end of this presentation in order to learn more about these interventions
to be able to determine what interventions might be most beneficial
for the specific students with whom you're working.
An aspect of intervention for an autism spectrum disorder that is unique to children
who are deaf and hard of hearing
is how the symptoms of an autism spectrum disorder
may impact the child, whose deaf and hard of hearing ability to use technology
that's available to them, like hearing aids and cochlear implants.
As I mentioned earlier, the research has indicated when we look at outcomes
of cochlear implant use for children, who are deaf and hard of hearing,
those with an additional secondary disability like an autism spectrum disorder
often do not perform as well as
typically developing deaf and hard of hearing children.
Parents of children, who have an autism spectrum disorder,
who are also deaf and hard of hearing, often report that their children benefit
from their technology and are able to show improvements in their ability
to respond to their name and respond to verbal requests and enjoy things like music,
but may have slower progress in their acquisition of speech and language
than typically developing children, who are deaf and hard of hearing.
However, this research is mixed, because one thing
that it doesn't look at is whether the children,
who have an autism spectrum disorder are getting intervention
for the symptoms of autism that we know can interfere
with their ability to acquire language and to use their technology
like their cochlear implants as frequently as their typically developing peers.
One thing that the research on outcomes for children with autism,
who are deaf and hard of hearing doesn't show us is the reasons
why they show slower rates of progress acquiring speech
or why their outcomes might differ from typically developing kids,
who are deaf and hard of hearing.
However, it's reasonable to think that some of what we know about symptoms
of autism can impact both their willingness to wear and use the technology,
as well as, how they respond once they are using the technology.
Because I commonly get questions about that first step of how to encourage
children with autism to use their technology,
I'm going to start there and provide some brief tips to encourage
use of cochlear implants and hearing aids for children for whom that might apply.
This intervention really requires collaboration between the child's audiologist,
their parents, and their other interventionists to be able to identify
where the challenge may be.
For children who are struggling to even tolerate
wearing an external device on their heads,
first it's important to rule out, whether the device is functioning properly.
Consultation with the child's audiologist is a reasonable first step.
For the majority of children, it's reasonable to think through
whether there might be some other sensory processing difficulty
that's impacting their tolerance for wearing the device.
A good clue to whether sensory difficulties might be impeding
your child's willingness to wear their hearing aids or cochlear implants
might be to think through whether they have sensory sensitivities to other things.
Are they struggling with things like cutting their hair or taking a bath at night?
Do they resist wearing other things on their head like hats?
Or do they resist touch overall, that isn't initiated by the child?
That might be a good indicator to tell you the child might have
some sensory processing difficulties that might be impacting
how well they can tolerate wearing a hearing aid or a cochlear implant.
If that's the case, then it's important to consult with the child's audiologist,
as well as, perhaps an occupational therapist to help you think through
some steps to desensitizing the child to wearing their device.
I'd encourage you to start small, to work towards wearing the hearing aid
or cochlear implant for a small amount of time.
Ideally to start with wearing the device during a highly enjoyable activity,
Something that your child really enjoys,
especially one where their hands are ideally occupied.
That might be playing in a sandbox, or playing in beads or beans,
or playing with Play-doh (if they like playing with Play-doh),
or playing a video game, or watching TV,
or technology, like an iPad, if that's captivating to them.
Ideally you would start during one of those activities that they really enjoy,
where their attention is diverted somewhere else,
and they're not focused on what's being placed on their head.
Then start with small increments.
Sometimes putting the hearing aids on their heads for a very short period of time.
Then removing them before the child has a chance to remove them.
The reason that this is important is that, if you remove it before they do,
before they indicate some discomfort then it helps build this association
between wearing the device and a tolerable experience.
Once you get to the point where the child is struggling with wearing the device,
they've already experienced some discomfort with it,
and it forms a negative association with the device.
Again the idea is to start small, make it all positive for the entire duration
that they have it on, even if that's a very short duration.
Then you can work on gradually increasing the amount of time,
that they're wearing the device.
Again trying to make it a positive experience for the child.
There might be some children for whom you need to take a step back
and perhaps start even further back with desensitizing them
to the idea of something touching their head or their ears.
There are ways to do this that are playful and feel less intrusive
to the child and to you, such as for the young child several times during a day
playing playful activities with infants and toddlers, where you might be playing
"Head, Shoulders, Knees, and Toes", but lingering over their ears or wiggling their ears
playfully as you do that and doing that several times throughout a day
over several days before even trying to get the hearing aids or cochlear implants on
to get them used to the idea of something touching their head.
You can do it playfully by also playing silly games,
where you have them wear funny hats or glasses or things like that,
just to get used to the idea of something being on their head or their face
in a playful, fun rewarding manner and then gradually building out
to putting the hearing aid or the cochlear implants on.
For some children it might be appropriate in consultation with their audiologist
to think about whether you put the hearing aid or the cochlear implant
on their bodies but don't activate it yet until they're able to tolerate the sensation
of something on their head without the added sensation of hearing something
that may or may not make sense to them initially.
As with all intervention for autism, it's really important to think through, "Why".
Why you're selecting the intervention, thinking through what might be
some possible explanations for why the child might be resisting wearing
their hearing aid or cochlear implant should be what guides
your decision in terms of how you choose to intervene.
We would intervene differently for the toddler, who's removing things
like their hearing aids and cochlear implants just because they're toddlers
and that's what toddlers do and the strategy might be
just to consistently put it back on until they become used to it,
versus the approach that we might take with a teenager,
who's resisting wearing their cochlear implant,
because they're afraid that it makes them look differently,
versus a child with autism who has sensory sensitivities
that makes it uncomfortable for them to wear the cochlear implant,
and therefore we need to desensitize them
to become more comfortable with it over time,
in order to encourage them to wear their cochlear implant.
Again in thinking through intervention in this regard,
thinking about what we know about autism can be helpful.
In some situations knowing what we know about autism, that children with autism
sometimes have special interest things, that they're intensely fascinated with
might be something that we can use in developing an intervention.
For example if a child really likes Elmo, or a certain color,
or Thomas the Tank Engine, you might be able to capitalize on that interest
by using a skinit or a cover or a sticker on their cochlear implant or hearing aid,
that makes them more interested and engaged with it
and more tolerant of it.
We know that children with autism can have sensory sensitivities,
so in addition to desensitizing them to being able to tolerate wearing
the hearing aid or cochlear implant, you might think through alternative ways
the wear the cochlear implant, like off the ear pinned up in the hair somewhere,
where it's less uncomfortable for them.
Again, you might also try wearing it turned off at first,
or wearing just the external part before wearing the internal ear mold,
and making sure that the sound is reinforcing to them
that the information they're getting through the hearing aid
and/or the cochlear implant is something
that they understand and that they're comfortable with.
Otherwise, sometimes it's helpful to modify
the volume on the devices in consultation with your audiologist.
Some children with autism can also be really rigid about things.
They can, for example, only want noodles,
if they're from a particular red package with a particular brand.
Again, if we're flexible about how we think about intervention, we might be able
to use it knowing that about the child in developing our interventions.
If a child has been resistant to wearing a hearing aid,
they don't like it, they're refusing to wear it,
they might be resistant to only wearing their beige or neutral colored hearing aid.
But once we work on desensitizing them to touch on their head,
we can reintroduce the hearing aid with a different appearance,
like a different colored ear mold or a skinit on it,
that in their minds might make it be something entirely different
than the one that they were so aversive to in the first place.
In reintroducing it as something different to them
and making it a more positive experience this next time around,
we sometimes seen some success with that with children with autism.
Again intervention really requires thinking flexibly,
being creative, and taking into consideration what we know about autism,
and what we know about technology for kids, who are deaf and hard of hearing,
to be able to develop a highly individualized intervention,
that's going to meet the needs of a specific child.