I begin with some basic premises:Approximately 90% of children with hearing loss develop in homes where spoken language is the basis for communication.
I begin with some basic premises:1. Approximately 90% of children with hearing loss develop in homes where spoken language is the basis for communication. For these children, spoken language development is usually a primary goal.
2. For most of these children, hearing aids and cochlear implants can provide hearing that is good enough to play its natural role in the development of spoken language.
3. Nevertheless, there are deficits of assisted hearing that need to be offset by intervention.
4. For the very young child, that means helping parents provide an enhanced learning environment
5. That environment, however, cannot focus only on hearing and speaking .Speech is only a medium for languageLanguage itself relates to what the child knows – that is cognitionThe need for, and use of language, is based on what people know about themselves and others – that is social cognition. Intervention therefore needs to address all aspects of development – especially cognition and social-cognition.
These premises provide the basis for what I have to say about children with hearing loss and the development of spoken language.
My first topic is the relationship between nature and nurture
We have long heard discussion about their relative importance.Is child development driven mainly by nature – genetically-determined sensory capacity, native intelligence, drives etc.Or is it driven mainly be nurture – the child’s physical and social environment.
The obvious answer is that development is driven by both nature and nurture -
- or, more exactly, by the interaction between the two. The contribution of each one is conditioned by the quality of the other.
Let us examine this interaction in a little more detailThe child’s learning environment essentially has three main parts. - the physical environment, the social environment, and the language environment.The physical environment consists of objects, events, their properties, and the many relationships among them – including the important relationship of cause and effect. The social environment consists of people, their actions (events), the properties of both, the relationships among them, the relationships between people and the physical environment – and, again, causes and their effects.The language environment involves a special kind of event that involves people and relates the physical and social worlds.These three aspects of the environment act on the child and the child reacts.The child also initiates actions and the environment reacts. Through these interactions, the child develops in several areas:Sensory and motor - including the sensorimotor skills involving speech. Perception - he learns to attend to and recognize objects, people, properties, and events on the basis of sensory input.Cognition – he develops an internal model of the physical world Social cognition – he develops an internal model of the social world and his relationship to it.Language – he develops a system of labels, and rules for combining them, to refer to, and externalize, aspects of his emerging inner world and social models. By a process of trial and error, this system grows ever closer to that used in his social environment. This development is conditional on the child’s sensory, motor, and intellectual capacities and is driven by innate drives.
Although I have described development in terms of five streams, it is important to remember that they are not independent. Every aspect of development influences and is influenced by every other aspect.This interrelationship is crucial when we address intervention designed to enhance spoken language development in children with hearing loss.First, we cannot focus only on speech. Speech is only a medium for language. Without language, speech is meaningless.Second, we cannot focus only on speech and language. Language refers to what the child knows about the physical and social worlds. Without cognition, language is impossible.Finally, language is used to interact with the world of people. Without social cognition, and the drive for social interaction, the child has no use or need for language – regardless of the medium. On a more positive note, once language has been acquired, its use provides an accelerated path for further cognitive and social-cognitive development. The child is no longer limited to physical interaction as a way of learning about the worlds of objects and people. The message, here, is that any intervention designed to speed the development of spoken language must also address its cognitive and social underpinnings.
I now return to the nature/nurture issue.
Our immediate concern is the child with reduced hearing capacity. He has a deficit of nature. Because of the key role of hearing in spoken language development and the role of language in overall development, this deficit has serious implications for the child’s development and, ultimately, her quality of life. This is probably the place to mention that my discussion is limited to the deaf child of hearing parents. In a family of deaf, signing parents, a hearing deficit is no barrier to the acquisition of signed language.
Assuming, however, that our goal is age-appropriate spoken language, our first task is to reduce the hearing deficit with appropriately fit hearing aids, cochlear implants, or both. This task falls to the pediatric audiologist, the surgeon, or both.But aids and implants only reduce the deficit, they do not eliminate it. In spite of advances in hearing assistance technology, and counter to the advertising claims of manufacturers and the hopes of parents, the aided or implanted child retains a hearing deficit. Depending on its magnitude this deficit can still slow or impede the development of spoken language.
This is where habilitative aspects of intervention come into play. To compensate for a residual deficit of nature we enhance nurture. Basically, we seek to enrich the physical, social, and language environments in order to promote learning and development in the areas of cognition, social-cognition, language, and speech.
The process of enhancing nurture for the child with hearing loss has many titles:Examples include: Aural habilitation, Auditory-oral intervention, Auditory-verbal therapy, Early intervention. Because it is the ideal input and feedback channel for spoken language acquisition, these titles often make reference to hearing, and hearing plays a key role in the process.Basically, there are three requirements:First is to make sure the child has the best possible hearing capacity. This means not only the provision, fitting, and programming or mapping of hearing aids and cochlear implants but also their ongoing monitoring and maintenance. With the introduction of multi-channel cochlear implants, good-to-excellent hearing capacity is now available to almost all children with hearing loss regardless of the degree of hearing loss. But, to be useful, hearing capacity must be converted into hearing skill which involves such things as alerting to, attending to, localizing, and recognizing events that generate sound.Finally hearing must be allowed to play the best possible role in development – not only of spoken language but also of the cognitive and social-cognitive skills on which language depends. As I shall point out, however, successful intervention involves much more than hearing.
So far I have made reference to learning and development but not to teaching. In fact, we cannot “teach” the child in the sense of imparting knowledge and skills by virtue of our actions. It is the child who learns and the ideal teacher is one who provides the child an environment and experiences that promote his learning and development. Fortunately our best ally is the child. Children are driven to learn about and acquire control over: themselves, their physical environment, and the social environment. In the absence of other deficits of nature, a hearing loss has no effect on this innate drive. The child’s drive for knowledge and control does not end with childhood but continues into adult life. It is best expressed in the scientist.
Scientific method begins with observation. Theories representour attempts to explain observations.To test a theory, we use it to make predictions about things not yet observed.Experiments are formal procedures to test these predictions.Results that follow expectations provide support for the theory but we continue to test it with new predictions.Results that are different from prediction require theories to be abandoned or modified and subjected to more tests.The process is cyclic and never ending and contributes to an ever-growing body of scientific knowledge.
The developing child follows exactly the same pattern. Theories and predictions are tested and results are used to support or reject them. The process is cyclic and never ending and leads to ever growing cognition, social cognition, and language.
The drive to engage in this process is part of the child’s nature. Our task, as interventionists, is to enrich the environment so as to optimize observations and the opportunities for experimentation. We do this through toy and play materials that engage the child in problem-solving activities, and through interaction with the child in shared activities both play and the activities of daily living. At all times, we include relevant language and we provide the results for his experiments with spoken language.
As we interact with the child the many layers of spoken language need to be considered.
These layers are nested within each other:The sounds of speech occur within words.Words occur within sentences.Sentences have a surface meaning, depending on the words it contains and the relationships among them.But sentences can also have a deeper meaning related to the talker’s intent or purpose.And the sentences are always produced in a context: the things present and their relationship to the child and each other the people present and their relationships to the child and each other the language that occurred before the current sentence.Taking full advantage of the physical, social, and language context is one of the things the child will learn.
A better analogy than a layer cake might be Russian nesting dolls.The child must learn the phonology of language, which exists within its vocabulary, which is used within the rules of grammar, to express meaning, which is chosen to satisfy the talker’s purpose, in ways that satisfy social rules related to language use. At any time, the interventionist may be focusing on one aspect of this process – modeling a consonant, introducing new vocabulary, modeling acceptable grammar, or pointing out acceptable usage. But he or she should never lose sight of the overall context. It is not good, for example, to ignore a child’s communicative intent in order to correct errors of articulation.
The different layers of language are dependent on sensorimotor function, cognition, and social cognition. The need to maintain a comprehensive understanding reminds us again that speech is only a medium for language, language is only a code for what the child knows and social cognition provides the drive and need for language.
I have talked of enhancing nurture by optimizing the child’s learning environment. But for the very young child, an interventionist has little direct control over that environment. The child’s physical, social, and language environment is determined almost exclusively by home and family.
The child learns and develops by interaction with the objects, people and language of his home.
Although the interventionist may interact with the child on occasion, most of the direct interaction will be between parent and child. The interventionist’s task is, therefore, to educate, guide, and coach the parents so that those interactions will provide an enriched learning environment. Parents also need to be trained and coached in the proper use and maintenance of hearing aids and cochlear implants and in ways of minimizing the negative effects on hearing of distance, noise, and reverberation. As the child gets older, the opportunities for direct interaction with therapists and teachers increases, but the home and family will still remain one of the main learning environments.
In the early stages of this process, parents who have just learned that their child is deaf are usually too involved in grieving and adjustment to be receptive to guidance or education. The good interventionist is sensitive to this issue and paces the intervention accordingly.Nowhere is the need for patience, support, and active listening more important than when first informing parents of the results of a hearing test. Regardless of what the audiologist or physician says, the only thing the parents will hear is that their child is deaf. The real work of intervention will begin later.
Once the parents have come to terms with the hearing loss, the process of indirect intervention begins with observation and evaluation of the child, the parents, and their interactive style. The interventionist also needs to provide information, explanation, and education about such things as:hearing loss,hearing assistance,intervention options,the importance of shared play,the best use of activities of daily living, the many strengths of themselves and their child.Most important is to provide demonstration and coaching in effective ways to interact with and communicate with their child that will enhance cognitive, social cognitive, and language development.Also important is to empower the parents and bring them to the realization that they are perfectly capable of raising a child with hearing loss and providing him with the skills and knowledge he will need for a productive, satisfying, and rewarding life. For the interventionist, success will come when he or she is no longer needed by the parents. This process is cyclical and continuous. It has successes and failures, rewards and discouragements. It demands much skill and sensitivity on the part of the professionals involved. It also requires coordination among them - physicians, audiologists, phoniatrists, language specialists, and teachers must work as a team. Disagreements and miscommunications only work to the detriment of the child.
As far as direct intervention with the child, whether by therapist or parent, the key is associations, relationships, and connections - between sounds and events, sound and movement, objects and objects, objects and events, sounds and words, words and objects, objects and concepts, words and concepts, words and properties, people and objects, people and people, causes and effects, sentences and meaning, etc. etc.
Here, in the simple example of playing with a hammering toy:Thechild is moving and experiencing the results through the senses of feeling, seeing, and hearing. The associations among them are promoting sensori-motor developmentThe association between the event and the sound is promoting perceptual development and, ultimately, cognitive development. As the therapist talks about what is going on, further associations between words and event, words and objects, words and properties, and words and experience promote language development.
All the activities of daily living – feeding, toileting, dressing, bathing – provide opportunities for cognition/language associations, as do play activities whether self-initiated or adult-initiated.
And all connections and associations with parents, adults, or other children serve to promote social cognition, social skills, and self-image. They are also opportunities to learn effective and appropriate use of language.
So far, I have stressed the importance of cognition and social cognition as bases for the development of spoken language. The good news is that the emerging language provides positive feedback in the sense that it enhances the very cognitive skills on which it is based.
To summarize:A deficit of hearing can compromise all aspects of development.
But this outcome can be avoided with enhanced nurture.
These then, are my primary messages.First, after everything possible has been done to reduce the deficit of nature caused by childhood hearing loss, we compensate for residual deficits by enhancing nurture.Second, the intervention should be holistic, acknowledging the intimate connections among cognition, social cognition, and language.Third, although cognition is the initial base for language, once acquired, language provides a powerful tool for further cognitive development.Fourth, for the very young child habilitative intervention is accomplished through parent education, support, guidance, coaching, and empowerment.
Childhood hearing loss and the development of spoken language
Childhood hearing loss and thedevelopment of spoken language Sordità e svilluppo del linguaggio parlato Arthur Boothroyd Presented during short course on Childhood Deafness and Language Amplifon Center for Research and Study Milan, October 2012 Course Director: Edoardo Arslan University of Padua
Premises1. Deaf children 90% have hearing, speaking parents
Premises5. Spoken language: Speech only a medium Cognition the basis Social cognition the need
Premises1. Deaf children 90% have hearing, speaking parents2. Aids & implants viable hearing3. Hearing deficits intervention4. Intervention mostly via parents5. Spoken language: Speech only a medium Cognition the basis Social cognition the need
Early child development Environment HomePhysical Family Social Language Child Development Sensori- motor Cognitive Linguistic Perceptual Social
Indirect intervention Indirect InterventionTherapist/teacher Family Child
What you say What they hearThe tests show that Mary has a hearing loss. Our best estimate is that the loss is around 85dB which puts her in the severe category. Thingscould be much worse. There’s a good chance shewill do well with hearing aids. If it turns out that the hearing loss is more serious, you needn’t worry because she can always be fitted with cochlear implants and we have been seeing amazing results with children. Some of them DEAF seem almost like they have normal hearing. Would you like me to explain the audiogram? Audiologist Parent Audiologist Parent
Indirect intervention Observation 0 ListeningEmpower- Diagnosis Explanation ment Support Demonstration
Direct intervention:Associations and connections EventsConcepts Sounds Move- Objects ment Sent- Words ences
Direct interventionTherapist child Parent child Moving Feeling Seeing HearingSensorimotor, Perceptual, Sound-event Cognitive, Linguistic association
Role of positive feedback Hearing Producing Speech Knowledge Use Language General Social Cognition Self
Inadequate nurture Hearing Producing Speech Knowledge Use Language General Social Cognition Self
Enhanced nurture Hearing Producing SpeechKnowledge Use LanguageGeneral SocialCognition Self
Messages1.Nature + Nurture development2.Holistic intervention cognition language speech social cognition language need/use3. Positive feedback Cognition Language Etc. Etc. Etc.4. Therapist family child