HEARING LOSS

 Functional Assessment Assignment

Disorder:  HEARING LOSS                                    ________________

You are a Vocational Rehabilitation Counselor working for a state VR agency office.  You have been assigned this client and are preparing for your first meeting by reviewing the client’s application for services.  The application has the client’s diagnosis but, at this point, no further medical information is given.  On the application, the client reports a desire to pursue training and/or employment.  This is all you know for now.

 

1.  Before meeting the client, you look it up.  What can you find out about the medical disorder or condition given as a diagnosis?  Do an online search of the disorder/condition and write a SHORT (1 – 2 paragraphs) medical description of the disorder/condition presented.  Include:

 

Description: Hearing loss is a partial or complete loss of the sense of hearing. There are four types of hearing loss:  conductive, sensorineural, central and mixed. Conductive hearing loss is the impaired transmission of sound waves through the external ear canal to the bones of the middle ear. Sensorineural hearing loss is or dysfunction in either the perception or the interpretation of the sound waves. Central hearing loss is when there are pathological conditions above the junction of the acoustic nerve and brainstem such as brain tumors that blocks the flow of blood to the structures of the inner ear.  Mixed loss is a combination loss of hearing, usually conductive and sensorineural.

A) Etiology: Hearing loss may have a genetic component, accounting for hereditary deafness in families.  But most deafness in infancy or early childhood can be attributed to prematurity, birth injuries, toxemia during the mother’s pregnancy, rubella, anoxia, maternal diabetes, maternal alcohol or drug use, childhood illness, and/or prolonged high fever. In older children or adulthood, causes may be attributed to chemicals, ear infections, physical trauma, and prolonged exposure to loud noise, or certain (ototoxic) medications.  Among the older population, aging (presbycusis) will often impact hearing. B) Onset: Hearing loss, depending on cause, can occur nearly anytime from pre-birth to old age.

C) Prevalence or Frequency:  According to statistics there are an estimated 36 million people in the U.S. who have some form of hearing loss. This is about 10% of the population. It is estimated that 3 in 10 people over the age of 60 have hearing loss. 1 in 6 baby boomers (ages 41-59), or 14.6% have a hearing problem. 1 in 14 generation Xers (ages 29-40), or 7.4%, already have hearing problems. At least 1.4 million children (18 or younger) have hearing problems and it is estimated that 3 in 1,000 infants are born with serious or profound hearing loss. (MarkeTrak survey,2004). 

D) Symptoms/Medications/Treatment: Symptoms of hearing loss vary widely; but they will always include a 1) loss of hearing, from mild to profound, and/or 2) distortion in hearing acuity to some degree.  Secondary symptoms of the hearing loss often include speech and language development delays.

Treatment often includes early intervention (if possible) to assist in the reduction of speech and language developmental delays. Treatment can begin before the age of six months. Treatment can include learning sign language (parents and individual) and amplification (hearing aids), and/or surgery, such as a cochlear implant.

Treatment:  There can be a wide array of treatments to address hearing loss which can depend on the type and source of the problem:

– Surgery can be performed as a treatment for several conditions such as a traumatic ear injury, genetic issues or malformations such as otosclerosis, scar tissue, tumors, or chronic infection. Often small tubes are surgically inserted into children’s ears that help to drain access fluid and equalize pressure.

– Hearing loss caused by infection can be treated with antibiotics or antifungal medications.

– Sensorineural hearing loss can be medically treated with corticosteroids to reduce swelling and inflammation.

– Meniere’s disease/tinnitus/vertigo can as well be treated by corticosteroids, a low sodium diet, diuretics, or even with surgery. Also, in recent years there has been implementation of physical therapy for exercises to improve vertigo and balance issues.

– Hearing aid devices that amplify sounds to aid individuals with auditory problems to hear things more clearly are also a popular form of treatment and can vary by a wide range of types, circuitries, sizes, and levels of power.

– Cochlear Implants are hearing aids developed for individuals with severe auditory difficulties resulting from dysfunctional cochleas. The base receiver must be surgically embedded into the skin behind the ear to stimulate nerve fibers present in the cochlea. It comes with a lightweight speech processor and a headset that is designed as a directional microphone and is fitted behind the ear. A small transmitter is then placed over the implanted receiver and is held in place there by magnets. Bone anchored hearing aids can as well be implanted which transfer sound by the means of bone conduction and stimulates the cochlea increasing audibility.

– Another way hearing loss can be addressed by a doctor removing ear wax that is causing blockage.

– If an individual thinks that their hearing loss stems from medication use, they can talk to their doctor about alternative drug options that do not have auditory side effects.

– There are other sound enhancing technologies such as personal listening systems, TV and radio amplifying systems, and several kinds of phone amplifying devices available. –

 

E) Side Effects Medications prescribed to treat hearing loss such as antibiotics, corticosteroids, and diuretics can unfortunately result in some negative side effects which can include: hyperglycemia, hypertension, GI bleeding or perforation, cerebral palsy, adrenal suppression, metabolic effects, jaundice, weakness, headache, dizziness, fatigue, photosensitivity, rash, vertigo, alopecia, fever, anorexia, cardiac arrest, congestive heart failure, pulmonary edema, vasculitis, acne, allergic dermatitis, impaired wound healing, increased sweating, menstrual irregularity, fluid retention, nausea, pancreatitis, ulcers, weight gain, loss of muscle mass, osteoporosis, tendon rupture, vertebral compression, convulsions, depression, emotional instability, euphoria, insomnia, meningitis, mood swings, neuropathy, personality changes, glaucoma, cataracts, or even death. Adverse effects can occur due to cochlear implants which can be: damage to the facial nerves causing temporary or permanent loss of facial movement on one side, implantation of the electrode into the cochlea can destroy any residual hearing in the implanted ear, the normal risks of surgical anesthesia or infection, loss of taste sensation on one side, fluid leaking from the ear or brain leading to meningitis, localized inflammation, loss of sensation around ear, tinnitus, vertigo or dizziness, skin wound infection, and inability to pursue medical exams such as MRI scans due to electrical impulses. Static electricity and water must be avoided as well as this can damage the implant. Bone anchored hearing systems can as well have side effects which can entail: discomfort caused by constant pressure of the device against the scalp, chronic infection, bleeding from the sinus, and meningitis.

 

F) References:

– http://www.webmd.com/parenting/help-for-parents-hearing-impaired-

  children

– http://en.wikipedia.org/wiki/Congenital_hearing_loss

– http://american-hearing.org/disorders/congenital-deafness/

– http://www.patient.co.uk/doctor/congenital-deafness

– http://www.asha.org/public/hearing/Congenital-Hearing-Loss/

 

2.  You also realize there will be functional limitations connected with the disorder or condition, and will want to ask your client about each one of them.  For each of the 5 factors, what do you expect MIGHT be impacted by this disorder/condition?  Review the anticipated functional limitations (-) for each factor.  What will the client be unable to do because of the disability?  Be as detailed as possible.  Then review the positives (+)—e.g., what functional abilities might remain, and what might be the positive impact of treatment (medication, therapy, etc.) or other interventions.  Again, be as specific as possible. 

 

a. Cognitive Functions: Address the following cognitive functions: (1). Attention/concentration (2) memory (both verbal and nonverbal) and (3) problem solving/ability to adapt. Do you expect this disability or disorder to compromise any of these 3 brain functions?

(-):  Cognitive function is not directly impacted by hearing loss, but it can be a secondary condition of hearing loss.  In a study done on children with hearing loss it was found that working memory, goal setting and execution of tasks as well as attention, were impaired compared to children without hearing impairments.  For older adults, in a study where participants with hearing loss underwent repeated cognitive testing over six years, cognitive abilities declined 30 to 40 percent faster than for those whose hearing was normal.  So there was a direct correlation between hearing loss and levels of brain function decline.  Older adults with hearing loss, on average, developed a significant impairment in their cognitive abilities 3.2 years sooner than those with normal hearing. Possible explanations for the cognitive deficits include the ties between hearing loss and social isolation, with loneliness being well established in previous research as a risk factor for cognitive decline.

(+): There is no direct relationship between hearing loss and cognitive problems.  With early intervention (through amplification, cochlear implants, or possibly surgery in some cases) and education, adoption of an effective communication strategy (e.g., sign language, auditory/oral training, and/or amplification), can reduce cognitive delays.

b. Sensory Functions: Address Visual, Auditory, Tactile, Olfactory, and Gustatory limitations that might or might not occur as result of this disability or disorder.

(-): Hearing is impacted in degree of loss and clarity; and interventions such as medical treatment, hearing aids, etc., may not help, or only help modestly.   As the aging process takes its course, hearing loss commonly begins to decline.  Damage to the vestibular organs of the inner ear, through disease (e.g., Meniere’s) or ototoxic medications (e.g., gentamicine and cancer chemotherapy drugs such as cisplatin and carboplatin) may cause dizziness.

(+): All visual, tactile, olfactory, and gustatory functions should be unimpacted.  With amplification devices (e.g., hearing aids, cochlear implant), assistive listening devices, and education, auditory function can be positively impacted.

c. Motor Functions: Fine and/or Gross Motor, Balance, Left or Right Body Side

(-): Damage to the vestibular organs of the inner ear, through disease (e.g., Meniere’s) or ototoxic medications (e.g., gentamicine and cancer chemotherapy drugs such as cisplatin and carboplatin) may cause or result in balance and gross motor disorders.  Dizziness may occur as a result of taking these medications causing unsteadiness on the feet.

(+): Usually no impact.

d. Emotional/Behavioral Functions: Any behavior that interferes with social or vocational functions. Do they have a DSM-IV diagnoses? How likely is denial or depression to occur during the course of recovery? Is substance abuse more likely to occur with this disability?

(-): Poor or incomplete adjustment to an acquired deafness can lead to emotional turmoil and depression. Denial is common and, according to the Hearing loss Association of America, it can sometimes take up to seven years or more for people to admit they have hearing loss. Depression and lack of interest in previously enjoyed activities have also been observed in many people who experience hearing loss due to being unable to communicate with other people or the feeling of being isolated from social events or discussion.

(+): Early deafness in children educated, and socializing, with other Deaf children, will normally have no negative emotional impact because there is usually acceptance of the disability, to include inclusion in the Deaf culture.  However, if the individual experiences emotional turmoil due to deafness—which more often occurs with a later, acquired hearing loss, or in families where it is not accepted–therapy might help with adjustment.  Early training in the use of accommodations such as amplification, assistive listening devices, and speechreading, can help the individual generally, or in specific environments to adapt socially to the hearing family, peers and co-workers.  Otherwise, acceptance of a profound hearing loss, and a Deaf culture (to include the use of sign language) can reduce stress and isolation.

e. Adaptive/Coping Functions: Address Work Adjustment problems that might occur as a result of this disability. Work adjustment is: (1) On-time (2) Dependable (3) Hygiene (4) Social Interaction. Might this disability compromise any of these 4 behaviors for any reason? Money management?

(-): Deficits are more likely to occur in the young, unused to commitments in school or work, or in adults due to an acquired deafness. 

(+): Most persons with long-established deafness, especially from an early age, have adopted accommodations to assist with timely wake-ups, transportation, and social demands.  In any case, adaptive/coping functions are often related to the individual’s own personal characteristics as well as family involvement/ support.  However, a person born Deaf (or deafened prior to language acquisition, usually before age 3), begins to develop his own social sphere, often apart from his own hearing family who may not be adept at communicating with him.  Friendships, relationships, courtship and marriage usually take place in a separate community of signing people.  They exchange information, support one another, adapt and cope with issues together, just as in any other culture.  If arriving on time and social interaction are limited or reduced, education and accommodation in the form of assistive listening devices can help.  But this may be supported and enhanced with the support of this culture.

3.  You’ve looked at personal, functional limitations.  Now look at possible job barriers (-) and accommodations (+) for someone with this disability.  For each of the following factors, list: 

(-) Job functions/factors you might expect to be problematic for one of this disorder/condition?  DO NOT LIST OR MENTION MEDICAL CONDITIONS OR FUNCTIONAL PROBLEMS (You already did that in section 2 above).

(+) Possible accommodations (+) to address the barriers (see Job Accommodation Network [JAN] (http://askjan.org/media/atoz.htm) for help here).

a. Executive function factors: such as planning, cognitive flexibility, abstract thinking, rule acquisition, initiating appropriate actions and inhibiting inappropriate actions, and selecting relevant sensory information.

(-): Jobs requiring written language, e.g., instructions, reference to technical manuals at reading level above 12th grade level might be an issue for those with congenital loss

(+): Use of sign language interpreter

b. Physical demands: such as standing/walking, lifting/carrying, climbing, balancing, stooping/ kneeling, crouching/crawling, reaching/handling/fingering, feeling, talking, hearing, tasting/smelling, visual acuity, depth perception, color vision, or field of vision.

(-): Jobs that rely heavily on verbal communication require detection and distinction of certain sounds, and jobs in noisy environments.  Jobs that require advanced reading levels might be problematic.  Jobs that require the use of sharp/hazardous/fast-moving objects could be dangerous if the individual experiences dizziness.

 (+):  Alternative modes of communication may be necessary between supervisor and individual or between co-workers, including personal technology (e-mail, IM, texting, etc.), use of sign language interpreter when necessary during formal staffing or training events, or simply note-writing.  Other technology could include telecommunication relay services, videophone, text telephone device, remote video interpreting, video relay conference captioning, or other assistive technology.

c. Environmental factors: such as exposure to weather, exposure to cold/heat, dust/smoke, wet/humidity, noise, vibration, atmospheric conditions, proximity to moving parts, exposure to electrical shock, working at heights, exposure to radiation, working with explosives, and exposure to toxic or caustic chemicals, other issues.

(-): Exposure to loud noises, proximity to moving/heavy parts, working near water, jobs that require the hearing/distinction of sounds (such as safety warnings), and areas with poor lighting. Audio signals/sounds to notify workers of operation changes, shift changes, breaks, etc. 

(+): Providing a quiet and well lit environment to maximize communication.  Ear protection in noisy environments, and personal amplification devices (e.g., hearing aids or ALDs) in normal, conversational environments.  Install vibration and flashing light safety devices for moving equipment or machinery, and in the event of an emergency.  Use buddy system where sound alarms may not be practical.  

d. Work schedule: such as long hours, fast pace, minimal breaks, reduced break-times, shift work.

(-): No impact, though changes in scheduling need to be presented in format readily understood—not orally. 

(+): Allowing for additional time for training in appropriate communication format(s) might be a consideration.

e. Worksite factors: such as parking proximity to entry; entry proximity to work station; spacing within entryways and passages in building; doorways, spacing and placement of sinks and stalls within restrooms; doorways and maneuver spacing in common/break rooms.

(-): Unmarked, or poorly marked or lit, traffic crossing from street or parking into worksite could be a safety issue.

(+): Accommodations could include strobe lighting, indicator lights, vibration devices to signal the client of individuals or equipment in passageways, coming around the corner, install mirrors to assist the client to see in blind spots and around corners, establish paths for travel of vehicles and machinery, enforce rules requiring moving equipment to stop and flash lights and beep horn at intersections, have a directional worker alert system to provide visual warning of oncoming vehicles, wearing a vest or hat to signal to other workers to proceed with caution.  Developing and practicing safety/emergency procedures, possibly using a buddy system, would be beneficial to ensure evacuation plans are understood by all parties.

f. Work station factors: such as proximity of tools, machinery, office equipment, computer/printer, etc. close to hand; ergonomic seating, etc.

(-): Work around noisy office equipment or machinery; or work around moving equipment, or reliance on audio alarms for such equipment, or in the event of smoke/fire.  Communication requirements:  with multiple speakers, in poorly lit areas, with telephone usage or in reception of guests or consumers.

 (+): A reduction in noise and distractions, and allowing the individual to work in a quiet space may improve communication and understanding. Providing a workstation that is well lit will improve the individual’s ability to lip read and see when others approach. Providing amplifier technology if the individual is required to answer the phone, and installing industrial mirrors to see others or equipment approach. Providing note materials, written instructions, dry erase board, computer messaging, computer speech-recognition software, allowing emailing or text messaging as an alternate form of communication, providing an interpreter when needed, and learning and encouraging the use of sign language. Installing vibrating cues or flashing lights for safety/emergency purposes (or even as reminders) will also be beneficial.

The (FAW example) attachment is for you to see how the assignment needs to be completed.
The (FAW Cardio-R) attachment is the assignment that needs to be completed. 

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Follow the instructions on the attached Functional Assessment Worksheet (FAW), beginning with a description of your client’s medical condition. Be sure to include all the elements requested in the description, a – e, to receive full credit for the assignment, as well as the strengths and weaknesses of this condition (#2), and job barriers and accommodations (#3).

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