First Language Acquisition in hearing impaired children with cochlear implants

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First Language Acquisition in hearing impaired children with cochlear implants

  1. 1. M.A.THESIS IN LINGUISTICSFIRST LANGUAGE ACQUISITION IN HEARING IMPAIRED CHILDREN WITH COCHLEAR IMPLANT L.C.SENEVIRATNE Department of Linguistics University of Kelaniya 2011 FGS/MA/LING/09/116
  2. 2. Contact;Chula Seneviratneseneviratne29@hotmail.com
  3. 3. DECLARATIONDeclaration by the candidate.I hereby declare that the work embodied in the thesis was carried out by me in theDepartment of Linguistics. It contains no material previously published or written byanother person. It has not been submitted for any degree in this university or anyother institution.Name: L.C.Seneviratne.Signature :................................... Date: 31st January 2012(Candidate)Certification of the above statements by the supervisor.I hereby certify that I have supervised this dissertation.Name: Professor G.J.S. Wijesekara.Signature:.............................................. Date: 31st January 2012(Supervisor) i
  4. 4. ABSTRACT This thesis talks about the language acquisition of hearing impaired childrenwith cochlear implant. Once they receive the CI only, these children gain the abilityto perceive language and then only they will be led to produce words after differentstages of L1 (first language) acquisition process. This is mainly because until thenthey are not being exposed to auditory input. Therefore, this thesis basically dealswith the contributory factors towards making L1 acquisition successful within CI(cochlear implanted) children. These contributory factors are age at implant, parentalsupport and the degree of rehabilitation. Consequently, it was also investigated howthese CI children acquire their first language (Sinhala language) and thedevelopmental stages in accordance with English language acquisition process. Thisonce again pays attention to find out the significances of language components withrelated to Sinhala language in their production. Nevertheless, this thesis stresses onthe appropriate language rehabilitation methods which would suit different agesbasically, the cochlear age (implant age) which means after CI children receiveauditory input. Various methods were used in collecting data in order to prove the topic ofthis thesis. Therefore, focus group discussions, telephone conversations,questionnaires, direct observation, interviews were used in the process of collectingdata. Overall, it was quite evident that one could easily reach the final conclusions ofthis thesis without any doubt due to the accurateness of these data collectingmethods. Still there could be differences in the levels and ways of L1 acquisition ofCI children since this is not unique to all. Therefore, it was identified that all the above factors contribute a lot towardsmaking these CI children learn their mother tongue in every aspect of language suchas phonologically, morphologically, syntactically etc. Nevertheless, it is expected toeradicate the misconception that, a HI child could easily acquire L1 merely with aCI, because ultimately it was proven that all the above mentioned factors are equallyimportant towards making L1 acquisition effective. ii
  5. 5. ACKNOWLEDGEMENTS I make this opportunity to thank all those who helped me in numerous waysto make this thesis a great success and it’s a pleasure to thank all of them. Initially, I will forever be indebted to two fabulous people for their direct andconstant support provided throughout this thesis. Without them I’m sure I wouldnever have been able to do this. They are my supervisor and my husband. My supervisor Professor G.J.S. Wijesekara played many roles being amentor, encourager, comforter and supporter at several instances. Whenever I wasin need of her help she always came up with a smile to help me irrespective of all herother busy schedules. Your gentle encouragement and proposals of creative optionstook me a long way in the course of this study. Nevertheless, I am really grateful toyou for giving guidance through your encyclopedic practice of linguistics whichreally inspired me. Next, I want to thank my dearest husband Jagath Seneviratne sincerely andwarmly, who rendered continuous support at every level. Your encouragement,affirmation and advice were immediately responsible for this achievement. Yourendless faith in me and commitment to raise me up through what you knew I coulddo (even when I didn’t) is the direct catalyst for me. Everyone dreams to have ahusband like you but I’m very lucky to have you. In the same way, I would like to give a big thank you to my two darlingdaughters Dinuki and Malki for their forbearance in my absence whenever I wasbusy with this research. Furthermore, there are so many other people who helped me in collectingdata and they all receive my heartiest gratitude. Among them Dr. A.D.K.S.N.Yasawardana , E.N.T. surgeon and Mrs. Thamara Perera, nursing officer are paiddue respect and gratitude at this moment for supplying me with data. The immense knowledge of cochlear implant which I gained fromWickramarachchi Institute of Speech and Hearing was mainly due to the helpinghand of its proprietor Mr. M. Wickramarachchi and to the professional collaborationof the rest of the staff. Among them Mrs. Preethi Peiris, my beloved friend, youhave become one of the strongest pillars behind this research, as you did not have a iii
  6. 6. second thought at any time in helping me. Thank you so much for beingcharacteristically generous. Moreover, my heartfelt gratitude goes to Mrs. Hema Fernando, a teacher, aspeech therapist for giving me every possible opportunity to investigate the L1acquisition in CI children who came to her for rehabilitation programmes. Dear parents, you have been so supportive to me by revealing all thenecessary facts which helped a lot in doing this research. Thank you so much foryour immense support. Last but not least, I would thank my dear CI children who have been with mefor several months giving me the fullest support to make this task a success. If not foryou all my dear children I will never have this prestigious opportunity. Once again, I owe my deepest gratitude to all the above individuals and allthe other people whose names are not mentioned but have assisted me one way oranother. iv
  7. 7. CONTENTDECLARATION...........................................................................................................iABSTRACT.................................................................................................................iiACKNOWLEDGEMENTS.........................................................................................iiiList of Tables.............................................................................................................viiiList of Figures..............................................................................................................ixList of Abbreviations....................................................................................................xCHAPTER ONE...........................................................................................................1 1.0 Introduction.........................................................................................................1 1.1 Classification of Hearing Impairment ................................................................1 1.1.1 Measuring Hearing Loss..............................................................................2 1.1.2 The Aim of this Thesis.................................................................................3 1.1.3 History of Hearing Aids...............................................................................4 1.1.4 History of Cochlear......................................................................................4 1.2 Objectives...........................................................................................................5 1.2.1 Parental Support.........................................................................................5 1.2.2 Age at implant..............................................................................................6 1.2.3 Language Development...............................................................................7 1 .2.4 Rehabilitation Process and Strategies.........................................................7 1.3 Research Problem...............................................................................................8 1.4 Research Hypothesis ..........................................................................................9 1.5 Research Methodology.......................................................................................9 1.6 Significance of the Research.............................................................................10CHAPTER TWO.......................................................................................................12 2.0 Introduction.......................................................................................................12 2.1. Way we hear....................................................................................................12 2.1.1 The sections of the ear...............................................................................12 2.2. Hearing Impairment.....................................................................................14 2.3. Cochlear Implant..............................................................................................18 2.3.1 What is a Cochlear Implant and how it works...........................................18 2.4. The CI surgery.................................................................................................22 2.4.1. Pre operative evaluation of a CI................................................................22 2.5. Factors which influence the efficacy of L1 acquisition in CI children............24 2.6. Conclusion.......................................................................................................26 v
  8. 8. CHAPTER THREE....................................................................................................27 3.0. Introduction......................................................................................................27 3.1. Parental Support...............................................................................................27 3.1.1. Responsibilities of these parents at different levels..................................29 3.1.2. Parental Support Towards L1 Acquisition................................................32 3.3 –Rehabilitation Process.....................................................................................38 3.3.1. Developing listening skills in CI children................................................39 3.3.2. Developing Speaking Skills......................................................................49 3.3.3. Some Activities used in Rehabilitation Programmes....................................51 3.3.4..Mainstream Education..................................................................................57 3.4. Conclusion.......................................................................................................58CHAPTER FOUR.......................................................................................................60LANGUAGE DEVELOPMENT IN CI CHILDREN................................................60 4.0 Introduction ......................................................................................................60 4.1 Introduction to Language Development.......................................................60 4.1.1- Language Development and Age at Implant............................................62 4.3. Language Development and Rehabilitation.................................................81 4.4. Language Development and Parental Support.............................................83 4.5. Social – Emotional Development of a CI child ..............................................83 4.6. Analysis of Language Acquisition in CI children. ........................................85 4.6.1. Auditory – Verbal Analysis......................................................................86 4.6.2.2.1. Phonological Development................................................................97 4.6.2.2.2.- Lexical Development.........................................................................99 4.6.2.2.3. Morphological Development...........................................................103 4.6.2.2.4. Syntactic Development.....................................................................105 4.7. Conclusion.....................................................................................................106CHAPTER 5.............................................................................................................108GENERAL CONCLUSION.....................................................................................108 5.0- Introduction...................................................................................................108 5.1. About Cochlear Implant.................................................................................108 5.2. Summary of Main Findings ..........................................................................109 5.2.1. Age Factor...............................................................................................109 5.2.2. Parental Support......................................................................................112 5.2.3. Rehabilitation Process.............................................................................112 5.2.4. Language Development..........................................................................113 5.3 Future Research Problems..............................................................................116APPENDIX 1............................................................................................................118 vi
  9. 9. APPENDIX 2............................................................................................................119APPENDIX 3............................................................................................................125BIBLIOGRAPHY.....................................................................................................126 vii
  10. 10. List of TablesTable 2.1 - Hearing Process 14Table 3.1 - Cochelear Implant Listening Skills Development 41Table 3.2 - Check Table 48Table 4.1 - Sounds of Speech 63Table 4.2 - Stages of Language Development In Children 64 viii
  11. 11. List of FiguresFigure 2.1 - Levels of hearing loss 15Figure 2.2 - OAE Report 23Figure 3.1 - Model of the aided audiogram 40Figure 3.2 - Ling-6 Sounds and their frequency levels 47Figure 4.1 - Audiograms 61 ix
  12. 12. List of AbbreviationsCI - Cochlear implantCI children - Cochlear implanted childrenHI - Hearing impairedL1 - First language (Throughout this thesis L1 of these CI children is considered as Sinhala language) x
  13. 13. CHAPTER ONE GENERAL INTRODUCTION1.0 Introduction This chapter will basically give a brief introduction about this whole researchwhich is based on language acquisition in hearing impaired children with cochlearimplant (CI). Furthermore, this will also discuss about age at implant, parentalsupport and rehabilitation as the main factors which contribute towards the efficacyof a CI.1.1 Classification of Hearing Impairment Hearing impairment is a disability which could be diagnosed at severalinstances. It could be identified prelingually as well as post lingually. Pre lingualhearing impairment means a child becoming deprived of auditory input beforeacquiring the language and post lingual hearing impairment means a person or achild becoming deprived of auditory input after acquiring the language. When wetalk about the pre lingual hearing impairment it could be once again classified indifferent ways. One instance of becoming pre lingually hearing impaired is basicallydue to heredity. Apart from that, other external factors like disorders within thechild’s auditory system could cause this impairment or it could be either due tocomplications during the pregnancy period. Anyway the symptoms for this kind ofpre lingual deafness would be the same in an infant irrespective of the cause ofgetting pre lingually hearing impaired. Post lingual hearing impairment occurs basically due to some illness after achild acquiring his or her mother tongue. Although here we stress on children, it doesnot mean that the adults are safe enough to be away from becoming hearing impaireddue to several illnesses. Meningitis is a very famous ailment which causes this postlingual hearing impairment. 1
  14. 14. 1.1.1 Measuring Hearing Loss This hearing impairment is measured basically in decibels hearing level(dBHL) which will be carried by a hearing health professional. The hearing testshown on a chart is called an audiogram. The amount of hearing loss is ranked asmild, moderate, severe or profound.They are as; • Normal hearing - Hear quiet sounds down to 20 dBHL • Mid hearing loss - Hearing loss in the better ear between 25-39 dBHL Have difficulty following speech in noisy situations. • Moderate hearing loss - Hearing loss in the better ear between 40- 69 dBHL Have difficulty following speech without a hearing aid. • Severe hearing loss - Hearing loss in the better ear between 70-89 dBHL Require powerful hearing aids or an implant. • Profound hearing loss - Hearing loss in the better ear from 90 dBHL Need to rely mainly on lip- reading and sign language or an implant.1 In order to overcome this impairment conventional hearing aids were used allthese years till the cochlear implant was being introduced to the world. After thisintervention almost all the people especially the parents of hearing impaired childrenwere very much enthusiastic of getting down the device to their children irrespectiveof its high cost.1 www.cochlear.au.com 2
  15. 15. 1.1.2 The Aim of this Thesis This thesis mainly talks about the efficacy of Cochlear Implantation withregard to language acquisition of hearing impaired (HI) Cochlear Implanted(CI) children. This also deals with other supportive factors which contribute a lottowards language acquisition of hearing impaired CI children, apart from the surgery.This research would be helpful in making hearing impaired CI children to grow up ina normal learning and living environment by fulfilling the other supportive factorswhich would increase the efficacy of the CI in the process of their first languageacquisition. Although there are many supportive factors which should be fulfilled inorder to get the maximum benefits of a CI. This research concentrates on the effectsof the parental support, age at implantation and the rehabilitation process after thesurgery. All these three areas are being considered as compulsory factors with regardto the efficacy of language acquisition of CI children. Nevertheless, the languagedevelopment of these CI children is also taken in to consideration. Not only that butmost of the literature reviews argue that the government too should he moresupportive in the course of supplying the CI device due to its high cost which isbeing undertaken by the private sector. If the government could make necessaryarrangements to import these devices, people could be benefited. This dissertation could be one of the early pieces of writing with relevance toacquisition of Sinhala language in CI children, although there are so many studieswhich are being handled with regard to acquisition of other languages as L1 in CIchildren. Therefore, this topic covers a wide area although this particular thesis aimsat handling L1 (Sinhala language) acquisition of CI children within the Sri Lankancontext. Nevertheless, it should be emphasized that this study contains the significantfacts about language development of CI children who belong to 2-6 years of age.Similarly, this will deal with the early development of L1 from the beginning ofreceiving a CI, as it is assumed that this age limit will contribute a lot towardsmaking L1 acquisition effective than any other age limit with regard to all the aspectsof language like clarity, stress, intonation patterns etc. which would once again helpthese CI children live in the society as normal children. The situation of hearing impaired children in the society is very pathetic dueto loneliness and depression which arise as a result of isolation. The main reason forthis is the inability of hearing impaired children to communicate with their friends 3
  16. 16. and loved ones and mainly due to the fact that they do not have the ability to accepttheir own disability. As a result to support these hearing impaired individuals theconventional hearing aids were invented.1.1.3 History of Hearing Aids Conventional hearing aids invented by Alessandro Volta in 1800, stimulatedhearing in hearing impaired individuals, with an electrical current by connectingbatteries to two metal rods, which later on were inserted into the ear. Volta describedthe sensation of it was similar to that of boiling thick soup which was ratheruncomfortable. Some 157 years later, the battery supplied electrical current was firstused to stimulate the auditory nerve in deafness. In the 1960 s and 70 s, greatadvances were made in the clinical applications of the electrical stimulation of theauditory nerve. This resulted in a device with multiple electrodes driven by an implantablereceiver and speech processor, the Cochlear Implant. Due to the technologicaladvances of the CI the efficacy of speech perception is emphasized irrespective ofthe age limit.11.1.4 History of Cochlear1982 – First commercially available 22 channel implant1985 – First to gain regulatory approval for adults1990 – First to gain regulatory approval for children1993 – First Auditory Brainstem implant1994 – SPEAK speech coding strategy introduced1996 – First implant to offer 10 year warranty1997 – Nucleus® 24M implant released1998 – 10,000 children with a Nucleus® implant First multi channel BTE speech processor1 http://en.wikipedia.org/wiki/Cochlear_implant 4
  17. 17. ACE™ speech coding strategy introduced1999 – Only cochlear implant approved for infants at 12 months Contour™ Electrode introduced2001 – Over 36,000 adults and children now implanted BTE introduced for Nucleus® 22 recipients2002 – Our 3rd generation BTE, ESPrit™ 3G introduced ADRO introduced to the SPrint™ body worn speech processor2004 – ESPrit™ 3G for Nucleus® 22 released1.2 Objectives Before the advent of CI, most individuals of hearing impairments managed tomaintain their auditory perception through conventional hearing aids irrespective ofthe shortcomings which those hearing aids had. Although sound clarity andintelligibility are attainable through hearing aids, they do not supply comfortablelistening. Due to these factors CI receives greater social acceptance. Although CIwas invented for the first time in 1982 it did not become very popular those days. Butfrom the year 2004 onwards it gained much popularity and in 2005 the first cochlearimplant took place in Sri Lanka. From that point onwards people tend to use it due tomany recommendations of the doctors. Although there was a huge trend towards CIworldwide, it is much less in Sri Lanka in comparison to other countries, may be dueto the high cost of the device. But still one could find a fairly considerable amount ofchildren who have undergone this CI surgery in Sri Lanka.1.2.1 Parental Support 5
  18. 18. Main objective of this study includes many areas connected to CI, such ashow well children with CI acquire their first language and about other supportivefactors which go hand in hand with the CI, to get the maximum benefits out of the CIand to enable those children to intrude into mainstream education. Thereby thisresearch intends to compare the level of language production and acquisition withand without much of parental support. Nevertheless, this research would once againfind out the effectiveness of first language acquisition against factors like, spokenskills of parents, integration of the family rehabilitation programmes conducted byspeech therapists and supported by parents.1.2.2 Age at implant Apart from the parental support which would help to get the maximumbenefit of a CI in the process of language acquisition, this study would also deal withthe findings of the most suitable age at which the CI should take place. Thisperspective of the CI would again support the fact that how well it would affect theprocess of L1 acquisition in CI children. Moreover, this would also pay attention towards the cause and age ofbecoming hearing impaired with connection to L1 acquisition process of CI children.This intends to find out how a child who has been normal in his hearing reacts afterbecoming hearing impaired due to several diseases like meningitis. Here it is debatedwhether a child who had proper hearing ability for some time would also becomesimilar in hearing impairment as a normal hearing impaired child by birth. For thesechildren, the efficacy of the CI in the development of oral language has shownsystematic improvement although they had had a proper hearing ability before. Themore they lack exposure to hearing sounds, the more they forget the language theywere used to. Therefore, they too tend to show more or less the same characteristicsof a hearing impaired by birth. However, further analysis of the language data revealsthat the development of L1 acquisition is not uniform across language domains aswell as in different children .This statement once again supports this thesis topic asthis too brings evidence to show that many more facts are responsible in developing 6
  19. 19. the efficacy in L1 acquisition in a hearing impaired CI child irrespective of any otherexternal factors like age or cause of becoming hearing impaired.1.2.3 Language Development With accordance to all the above factors, these CI children were observedsimultaneously to find out their developmental stages in acquiring L1. Acquisition oflanguage within these CI children was identified under several perspectives such asphonologically, morphologically and syntactically. Moreover, it was tested underaudition, language, speech, cognition and communication too. Nevertheless, L1acquisition of these CI children was investigated with comparison to languagedevelopmental stages of a normal hearing child as it is more or less the same withinthe CI children after the proper auditory input, except in post lingual hearingimpaired.1 Since most of the standard findings about language acquisition is relatedto English language, those specifications were taken into consideration and werecompared with the acquisition of Sinhala language elements and investigated aboutsimilarities and differences between those two languages.1 .2.4 Rehabilitation Process and Strategies Another factor which is equally important in making a CI effective in theprocess of language acquisition is rehabilitation. This is mainly taken in toconsideration in this thesis as most parents have the misconception that the CIsurgery itself would totally benefit their children in acquiring their language.Therefore, most of the parents do not pay much attention to send their HI children tospeech therapists. Although it is intended to talk about the above facts separately, all thesefactors have equal importance in the field of making a CI surgery effective towards1 http://www.cochlear.com/files/assets/Listen-Learn-and-Talk.pdf 7
  20. 20. language acquisition. Therefore, the main objective of the present study is to lay abetter concept as to how a hearing impaired child would be benefited with a CI inisolation and how effective it would be in providing sufficient access to auditoryspeech input in acquiring language. This would also be an eye opener to thecaregivers, therapists and parents of CI children as to how and what factors should betaken into consideration in order to get the maximum benefits out of a CI.Nevertheless, this would provide some kind of an idea as to how these CI childrengrasp and develop L1 through different stages of acquisition.1.3 Research Problem The area of this research deals with the possibility of developing orallanguage in hearing impaired CI children. Since the language acquisition process ofthese children are not uniform ,this is meant to find out the causes for it and at thesame time the possible measures one could take in order to develop this. Thereby,this piece of writing would deal with the external factors which contribute towardsthe efficacy of language acquisition, production and perception of a CI child. Firstly,it is argued whether the CI surgery in isolation would he sufficient for a hearingimpaired child to possess normal hearing and if not what other factors should begiven prominence such as the age at implantation, the cause for being hearingimpaired, parental support and the rehabilitation programme. Above all, thedevelopmental process of language acquisition within these CI children also has beentaken into consideration. This would help in finding the different stages of languageacquisition of a hearing impaired CI child. Most of the literature reviews believe on the efficacy of the Cochlear Implantaccording to the age of the surgery; thereby, most of the medical officers say that theearlier a child under goes a CI, the easier that child acquires the oral language.Therefore, the sample data will prove the most appropriate age limit which wouldenhance to gain the maximum benefits from a CI. Nevertheless, the teachingmethodology , its specifications will also be taken into consideration At the sametime the practicality of handling children with CI, the steps to be followed in 8
  21. 21. rehabilitation starting from auditory-visually which would later on can he presentedauditory alone.1.4 Research Hypothesis Although this study is divided into several areas like how parental support,age at implant and rehabilitation process affect in developing L1 acquisition withinCI children, it was clearly identified that all these factors are equally importantsimultaneously in order to get the maximum efficacy of a CI. Thus, HI children willnever achieve a good level of language proficiency if not for the collective effort ofall the above factors. Nevertheless, it was quite evident that the children, who receivea CI early in life, are better in L1 acquisition than who receive it later.1.5 Research Methodology The sample data which is used in this research is mainly children below 8years. These children once again could be categorized under several perspectives.According to the objectives in this research the sample data is divided as the age ofbecoming hearing impaired, whether by birth or later due to some other external orinternal factors. Apart from that the cause of becoming hearing impaired is also takeninto consideration and thereby how their levels of language acquisition vary. Anotherperspective of categorizing these children is with reference to the age at CI whichwould be more helpful in drawing conclusion in language acquisition of CI children. The sample data was again categorized according to the level of parentalsupport and how effective the CI children acquire their first language along with that.Nevertheless, when it comes to parental support the rehabilitation process of thetherapists also was assessed as to what factors and methods should be taken intoconsideration when it comes to uplifting language acquisition, production and 9
  22. 22. perception process of a CI child. Therefore, the research methodology of this thesisdeals with the education, economy and psychological status of parents and theteaching methods followed in rehabilitation process. These were observed in order tofigure out the efficacy of language acquisition of CI children. Particularly, almost allthe data was gained through the methods of observation, questionnaires, interviewsand focus group discussions. Focus group discussions were very much helpful indrawing conclusions as they demonstrated great assurance in their authenticexperience which really matched with the findings too. The age group of this research varied from 2 years to 6 years which includedchildren with hearing impairment by birth as well as due to other ailments likemeningitis. Some of these children had been once exposed to the normal life but theylater on got this hearing impairment as a side effect of meningitis. But they even lateron showed impairments in auditory input. They show more or less the samedeficiencies as a child of hearing impaired by birth, even they knew a set ofvocabulary earlier and led a normal life. Moreover, the tendency of forgetting the socalled earlier used vocabulary grows higher with the hearing loss since the auditorynerve doesn’t stimulate as a normal child. The sample was once again observed under a teaching / rehabilitationenvironment at the very beginning since they were unable to produce languagespontaneously at the early stage of CI. Therefore, the L1 production of these CIchildren was investigated step by step with the help of stimuli. Nevertheless, othermethods like questionnaires and focus group discussions were very much helpful indrawing conclusions.1.6 Significance of the Research Significance of this research mainly lies on the focus of the acquisition of L1in hearing impaired children with cochlear implant. Moreover, this deals with theefficacy of it in relation to parental support and rehabilitation as well as the age atimplantation. Language acquisition of these children is being taken into consideration withrelevant to the cause and age of hearing impairment and at the same time it is also 10
  23. 23. considered whether the age at implant creates any impact on the progress of L1acquisition in CI, hearing impaired children. Although this is a fact which should get social consideration and mainly thegovernmental consideration due to the high cost of the CI device, it is not beingfulfilled yet. Due to the psychological impact in HI children as well as their families,adequate measures should be taken in order to eradicate the psychological stresswhich this group of people under goes. This would also be a timely and useful study as most parents of CI childrenstruggle a lot in establishing proper auditory speech input within their children afterthe surgery. Nevertheless, this will give proper guidance as to how people in thesociety should act with relevance to hearing impaired children as they undergosevere mental trauma due to their inability to stand on their own in the normalsociety.1.7. ConclusionAs the conclusion of this chapter, it could be stated that the rest of the thesis will dealwith all the above factors which come under objectives by using the specifiedmethodology. It can be also emphasized that through the findings of this research itwas easy to figure out the hypothesis clearly. 11
  24. 24. CHAPTER TWO COCHLEAR IMPLANT2.0 Introduction This chapter focuses on giving a brief description on the process of hearing,the sections of an ear, hearing impairment, classification of hearing impairment,categorization of ages at onset as in pre-lingual deafness and post-lingual deafness,about the CI as a device and how it works in the field of supplying auditoryperception. The advent of hearing loss should be initially done by the parents, as thataffects the efficacy in every other way of a CI operation. Therefore, this chapterwould be very helpful in knowing about hearing impairment and the symptoms of itin order to take necessary steps to eradicate the defects caused due to hearingimpairment.2.1. Way we hear The following details bring out a brief description about the parts of the ear andhow it works. Nevertheless, this will give a clear idea as to what disabilities make aperson hearing impaired.2.1.1 The sections of the ear There are three major parts to the ear and they are outer ear, middle ear andinner ear which is called as the cochlea. These different parts work in different waysin helping a person to have proper auditory input.Outer ear - catches the sound waves and directs them into the middle ear. 12
  25. 25. Middle ear - transfers sound waves in air into mechanical pressure waves that are then transferred to the fluids of the inner ear.Inner ear (cochlea) - turns pressure waves into sound signals that our brain can understand.1See  Appendix 3 (Video Clip No. 1)2.1.2. Hearing Process Picture 2.1 - Hearing Process1 ( http://www.cochlear.com/au/hearing-and-hearing-loss/how-hearing-works-children) 13
  26. 26. Table : 2.1 Hearing Process 1 Sounds enter the ear canal2 The ear drum and bones of Sound waves move through the hearing vibrate ear canal and strike the eardrum. These sound waves cause the eardrum, and the three bones (ossicles) within the middle ear, to vibrate. 3 Fluid moves through the inner4 Hearing nerves talk to the brain ear The hearing nerve then sends the The vibrations move through the information to the brain with fluid in the spiral shaped inner ear electrical impulses, where they – known as the cochlea – and are interpreted as sound.1 cause the tiny hair cells in the cochlea to move. The hair cells detect the movement and change it into the chemical signals for the hearing nerve.See  Appendix 3 (Hearing Process) (Video Clip No. 2)2.2. Hearing Impairment Hearing impairment is a condition which makes an individual completely orpartially impaired in detecting certain frequencies of sound. There are different typesof hearing losses. They can be categorized as conductive hearing losses andsensorineural hearing losses. Mainly sensorinueral hearing loss can be treatedthrough CI. This type of hearing loss occurs mainly due to the problems in thecochlea in the inner ear, or along the auditory nerve which leads to the auditory areasin the temporal lobe of the brain. Heredity and diseases like meningitis are mainly1 ( http://www.cochlear.com/au/hearing-and-hearing-loss/how-hearing-works-children) 14
  27. 27. regarded as common causes for this type of hearing loss.1 Many people suffer fromhearing loss because they have damaged hair cells in the inner ear (cochlea). If somehearing nerves still work, a CI can allow that person to hear well.2 Anyway, these various types of hearing impairments should be measuredthrough audiograms before any treatment. Therefore, audiologists and E.N.T.surgeons decide on the appropriate medication for HI children or adults with the helpof the results of the audiogram. Here is a sample set of audiograms which reveals different types of hearingimpairments: These stages are quite clearly indicated through these audiograms Figure - 2.1 - Levels of hearing lossThis audiogram shows normal hearing.Sounds below the lines on the audiogram can be heard.X shows the left ear.0 shows the right ear.All the X and 0 are above the 20line. This means hearing isnormal.Range of hearing loss A hearing loss can be mild, moderate, severe or profoundThis audiogram shows a mild hearing loss.Sounds below the lines on the audiogram can be heard.1 Strategies for including children with special needs in early childhood settings : by M. Diane Klein,Ruth E. Cook, Anne Marie Richardson- Gibbs)2 (http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults) 15
  28. 28. All the X and 0 are between the 21and 40 lines.This is a mild loss.This is a moderate hearing loss.Sounds below the lines on the audiogram can be heard. Low/loud sounds like oo, ah,ay and ee may be heard.All the X and 0 are between 41 and70.This is a moderate loss.The hearing loss in the left ear isworse than the right ear.This is a severe hearing loss.Conversational speech cannot be heard. Shouting and loud noise (like traffic) can beheard.All the X and 0 are between 71 and95.This is a severe loss.This is a profound hearing loss.Speech cannot be heard. Very loud noises like pneumatic drills and planes taking offcan be heard (or felt). 16
  29. 29. The X and 0 are mostly below the95 line. This is a profound loss.People with very profound hearinglosses can feel loud low sounds. To work out the level of hearing loss 1. Add the Hearing Level (dB) for 250, 500, 1000, 2000 and 4000Hz in the better ear. 2. Divide by 5. 3. If there was no response use 120dB. 12.2.1. Pre Lingual HI and Post Lingual HI Hearing loss could be varied as pre-lingual hearing loss and post-lingualhearing loss whereas pre-lingual hearing loss takes place before a baby starts talkingand post-lingual hearing loss takes place in individuals later in life. In this researchboth types of hearing impairments have been taken into consideration. To diagnoseeither of the hearing impairments one should be aware of the symptoms and mainlythe parents should work closely to the child since it is a silent, hidden disability. Thisis mainly visible in pre-lingual hearing loss since it is something to do with babieswho cannot communicate.2.2.2. Symptoms of HI1 http://www.schooltrain.info/deaf_studies/audiology2/levels.htm 17
  30. 30. But still if the parents are aware of several age appropriate behaviours of thebaby, then they will easily figure out this disability. Likewise, the sample set ofparents in this research has observed some of the following symptoms which hadbeen useful to them in order to make early diagnosis of hearing impairments of theirchildren. Among them pre-lingual hearing losses have been diagnosed by someparents due to several behavioral patterns which are not normal. One baby between0-4 months of age has not awaken for sudden noises during the sleep. Furthermoreanother parent complained about her baby who did not turn towards sounds that wereout of sight at the age of 4 months, which once again has led her to a pediatrician.Nevertheless majority of the parents have diagnosed about their children’s disabilitydue to the abnormal babble sound during the age of 6-7 months. Some parents havecome across their children producing only the vowel sounds when the same agechildren are far ahead in producing different sounds. Therefore these symptomswould lead to pre-lingual hearing losses. According to this research it contains pre-lingual as well as post-lingualhearing impaired children. Therefore it was easy to find out the symptoms of post-lingual hearing impaired children through their parents. Most of the post-lingualhearing impaired children have undergone meningitis and as an after effect of thatdisease they have been disabled. Thus, those parents complained about severalbehaviours of their children after meningitis such as frequently asking others tospeak more slowly and loudly, turning up the volume of the television or radio,difficulty in understanding words especially against background noise and avoidingsocial settings or conversation. These abnormal behaviours have led them to medicaladvice which had later on ended in CI operations.2.3. Cochlear ImplantThis part of this chapter talks about the device , cochlear implant, which is going tobe the most important part of this whole thesis, because if not for the CI none ofthese severe to profound hearing loss children will be enabled to acquire language intheir life.2.3.1 What is a Cochlear Implant and how it works 18
  31. 31. Cochlear Implant is the main issue of this thesis which from now on in thischapter would be dealt with. A CI is a small complex electronic device which issurgically implanted that can help to provide a sense of sound to a person who isprofoundly deaf or severely hard of hearing. This is often called as a bionic ear. Animplant does not restore or create normal hearing. Instead, under appropriateconditions it can give a deaf person a useful auditory understanding of theenvironment and help the recipient to understand speech. Thereby it would make therecipient succeed in mainstream educational setting. The basic implant system consists of an implanted electrode array andreceiver – stimulator and an externally worn microphone, transmitter and processor. 1The device is surgically implanted under general anesthetic and the operation usuallytakes from 1 ½ to 5 hours. Firstly a small area of the scalp directly behind the ear isshaved and cleaned. Then a small incision is made in the skin just behind the ear andthe surgeon drills into the mastoid bone and the inner ear where the electrode array isinserted into the cochlea. After 1-4 weeks of healing, the implant is turned on or activated. Although itis activated, as most of the parents expect, results are typically not immediate since itneeds time for the brain to adapt to hearing new sounds. During this period post-implantation therapy is required with the fullest effort of parent –professionalinvolvement. When we talk about the CI as a device and its operations it is a very complexprocess. All cochlear implants have two main components out of which the internalcomponent is implanted as it is mentioned earlier, where as the external componentis worn outside. The external component consists of a microphone, an externaltransmitter and a signal processor or referred as a speech processor. The microphonepicks up sound from the environment. The speech processor then selects andarranges sounds picked up by the microphone. The internal component too plays amajor role as the external component. Since the internal component consists ofelectrodes that are implanted into the cochlea, they collect the impulses from thestimulator and send them to the brain. The incoming sound is analyzed by the signalprocessor and computed into fundamental acoustical information. These representthe key elements of human speech.21 (Amy Mc Conkey Robbins)2 ( (Leading Article Cochlear implants in children Devanand Jha1 Sri Lanka Journal of Child Health,2005; 34: 75-8) 19
  32. 32. 2.3.2. Parts of a CI Picture 2.2 - Parts of a CI 1. A sound processor worn behind the ear or on the body, captures sound and turns it into digital code. The sound processor has a battery that powers the entire system 2. The sound processor transmits the digitally-coded sound through the coil to the implant 3. The implant converts the digitally-coded sound into electrical impulses and sends them along the electrode array placed in the cochlea (the inner ear) 4. The implants electrodes stimulate the cochleas hearing nerve, which then sends the impulses to the brain where they are interpreted as sound.2.3.2.1. Cochlear implant components Picture 2.3 : Parts of a Cochlear 20
  33. 33. Sound Processor Implant1See  Appendix 3 (Video Clip No. 3) (Parts of a CI)2.3.3. The benefits of a cochlear implantMany adults with cochlear implants report that they: • Hear better than with a hearing aid Study showed an average 80% sentence understanding, compared with 10% for hearing aids1 • Can focus hearing in noisy environments Converse with people across meeting tables, in restaurants and other crowded places • Reconnect with missed sounds The sound of the rain • Feel safer in the world Hear alarms, people calling out and approaching vehicles and know where they are. • Talk on the phone • Enjoy music1 http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults 21
  34. 34. 2.3.4. Factors which affect the benefits of a CI • How long they have had hearing loss • How severe their hearing loss is • The condition of the cochlea (inner ear) • Other medical conditions • Practice using their cochlear implant system12.4. The CI surgery Although we talk about the cochlear implant surgery as the basic need to acquirelanguage within these HI children, there are so many other factors which should becompleted before the surgery. These steps could be basically categorized as preoperative stage and post operative stage, where pre operative stage pays a great dealof attention to find out the eligibility of the HI child for the surgery and the postoperative stage deals with the checking of the auditory level of these HI, CI childrenand about their rehabilitation programmes.2.4.1. Pre operative evaluation of a CI When we consider a CI operation, preoperative evaluation is given muchprominence since the progress of the whole surgery depends on this and neverthelessit assures the child’s health security even after the operation. Therefore, aspreoperative preparation selection of candidate, radiological assessment,psychological and social consideration is taken into consideration. Moreover plansfor postoperative operations are also being discussed and planned out before thesurgery since it too plays a major role in the process of L1 acquisition within ahearing impaired CI child. Therefore, postoperative preparation contains surgicalprocedure and rehabilitation programming.1 http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults 22
  35. 35. A surgeon (E.N.T), an audiologist, a speech-language pathologist and ateacher for the deaf are responsible for the candidate selection since it is amultidisciplinary evaluation. Figure 2.2 - OAE Report This is a pre operative evaluation of a HI, to check the functions of thecochlea.2.4.2. Candidacy Selection 23
  36. 36. There are several factors that determine the degree of success to expect fromthe operation and the device itself. Therefore candidate selection takes place onindividual basis. Thereby a person’s hearing history, cause of hearing loss, amount ofresidual hearing, speech recognition ability, health status and family commitment toaural rehabilitation are considered before a CI surgery.1 The selection criteria for inserting a CI in hearing impaired children are asfollows, those children should be twelve months of age, however, even before oneyear of age a child can be implanted when meningitis is the cause for the hearing losssince meningitis causes ossification in cochlea as time passes rendering electrodeinsertion more difficult. Moreover a child should suffer from bilateral sensorineuralhearing loss and at the same time that child is not benefitted from hearing aids. Thusthe child should be checked for medical contraindications before the surgery. Thisbrings only a brief set of criteria for candidate selection whereas it is a verycomplicated matter. Not only the physical perspective of the candidate but also the psychologicalperspective of the candidate should be examined before the operation. Thereby onceagain it shouldn’t only be of the candidate but of the parents and other familymembers too since they have a vital role to play after the operation which wouldinfluence a lot in the efficacy of L1 acquisition.2See  Appendix 3 (CI surgery – DVD No. 2)2.5. Factors which influence the efficacy of L1 acquisition in CI children There are so many factors which influence speech recognition by childrenwith CI. All these facts are responsible for the efficacy of L1 acquisition in CIchildren. They are,1 http://en.wikipedia.org/wiki/Cochlear_implant2 (Devanand Jha) 24
  37. 37. 1) Implant technology.2) Surviving neural population.3) Auditory (sensory) deprivation.4) Auditory pathway development.5) Plasticity of the auditory system.6) Length of deafness.7) Age at time of implantation.8) Etiology of deafness.9) Preoperative selection criteria.10) Preoperative hearing level.11) Preoperative auditory speech perception.12) Measures of speech perception. (preoperative and postoperative)13) Preoperative linguistic level.14) Other handicaps.15) Surgical issues.16) Device programming.17) Device/equipment malfunctions.18) Mode of communication.19) Auditory input.20) Frequency type of training.21) (Pre) school environment /education setting.22) Parental/family motivation, social issues.1 Although CI surgery is regarded as only one process on the surface level, itincludes several other areas to be fulfilled, which are mentioned above to get themaximum out of a CI in a hearing impaired individual. Still most of the issuesmentioned in the above list are beyond the scope of this research, this would dealonly three factors which would influence the efficacy of L1 acquisition in hearingimpaired CI children such as age at implantation, parental support and rehabilitationprogrammes.1 Amy Mc Conkey Robbins 25
  38. 38. 2.6. Conclusion This chapter dealt with a brief idea of what is meant by hearing impairment,how to figure out this disability in the stages of pre-lingual and post-lingual hearingloss, about the cochlear implant as a device, how it is being inserted, pre and postoperation management of a CI etc. Since this describes as to how a parent couldfigure out the earliest stages of his/her child’s disabilities it would be very muchimportant to get the earliest treatment as possible since it would maximize theefficacy of L1 acquisition of that HI child with proper medical care and neverthelessthis child will not be left alone in the society since he/she can educate in themainstream schools which would once again be a supportive factor in the growth ofhis/her personality development. 26
  39. 39. CHAPTER THREE SUPPORTING FACTORS3.0. Introduction This chapter deals with some of the supportive factors which would influencethe efficacy of L1 acquisition in hearing impaired CI children apart from the medicaltherapy these children get. Under these supportive factors, the effectiveness of L1acquisition is measured according to parental support, rehabilitation process and theage at implant. With regard to both parental support and rehabilitation there shouldbe proper sequential order which would be compatible with the implant age of a CIchild. Therefore, many audiologists have done several researches and have come toconclusions as to how these CI children should be rehabilitated. This chapter givesan overview of these methods which are being adopted by the therapists in theirtherapy sessions and how far they have motivated the parents of these CI children tohelp their children. Simultaneously, almost all the facts show some kind ofdevelopment with regard to early age at implant. All the developments with CIchildren who received their CI as early as possible show a speedy development in L1acquisition, while the other CI children reach that level with much more timeconsuming. Nevertheless, it should be insisted that most of the researches withregard to CI children language development are handled associating Englishlanguage, but this thesis has made use of all those theories in such a way whichwould relate to Sinhala language, as the L1 of the sample set of CI children belongsto that.3.1. Parental Support Firstly, it is intended to discuss the fact of parental support and how effectivea CI child acquires his or her L1 with the help of the parents. This should not only bethe parents but it could be the responsibility of other family members and closefriends too. This is more important mainly in the field of psychosocial, in the process 27
  40. 40. of socializing HI, CI child. Therefore, although the main aim of this research is tofigure out the efficacy of language acquisition in hearing impaired CI children, thebehavioural patterns of the parents of these CI children, their economical status, theirlevel of education, their ability in psychological adjustments and their social statuswere taken into study. Those data were later on analyzed and compared with the L1acquisition of CI children and thereby it was easy to draw conclusions as to howparents with hearing impaired children should act to get the maximum benefits of aCI apart from a successful surgery. Therefore, this would surely be an eye opener tothose parents who are really enthusiastic of intruding their HI children intomainstream education. From the beginning of this research the importance of the parental involvementwas very significant since they have given their children proper medical care.Almost all the parents involved in this research, have taken proper decisions atcorrect time due to their keen observation irrespective of their social status and thelevel of education. Nevertheless, although most of the parents in this sample study donot obtain a higher economical state, they have somehow or the other managed tocover the high cost of this CI surgery which in one way seems very pathetic. Thissituation once again creates great impact on the efficacy of L1 acquisition in HI childalthough it doesn’t seem directly. Some parents were really honest at moments whenthey came out with their real emotions which have suppressed them due to the heavycost of the CI and therefore they rather regret in neglecting their children in therehabilitation programme. This is mainly due to their inability in positive stressmanagement. Therefore, as postoperative measures of a CI the parents with CIchildren too should be provided with regular counselling programmes according totheir level of education. Although some parents with CI children are highly qualified,they lack the ability to cope up a situation like this throughout their life span sincethis would ultimately become a real burden handling a CI child in a family. Thischapter identifies the stresses of parents with CI children, tied directly to the situationand talks about the psychological adjustments which should be altered within them.This problem should be solved in such a way since it affects the process of L1acquisition in HI, CI children due to the lack of attention they get from their parentsand other family members who have undergone lot of mental trauma. Therefore,mental up liftment programmes for these parents, should be implemented by the 28
  41. 41. health sector simultaneously with the CI operation in order to make the CI childrengrasp their L1 more effectively.3.1.1. Responsibilities of these parents at different levels When we consider the involvement of parents toward these CI children, itbegins from the point at which they diagnose the disability of hearing impairment oftheir child, which could be categorized as pre-lingual hearing loss and post-lingualhearing loss. The symptoms which led them to recognize their child’s disability werestated in chapter two. Therefore, the necessity of proper parental care is very muchevident in every aspect of this cochlear implantation .Thus this chapter focuses onbringing out the importance of proper involvement of parents with CI children toraise the efficacy of language acquisition within their children. The involvement of parents could be observed step by step from the time ofdiagnosis and giving them proper medical therapy rather than ignoring the disabilityin order to maintain their social level. Once their children are taken to an E.N.T.surgeon, it is the parents who have to face the crucial stage of finding the high costneeded which they find it with much effort ,being citizens in a third world countrylike Sri Lanka. Then they have to have proper education in order to understand theadvantages as well as the disadvantages of this operation since there are so manyirreversible points after an implantation. Therefore the parents should be informedabout them and should negotiate with them in order to know whether they are readyto take the risk. Even just after the operation the parents of CI children should be wellinformed about the steps they should follow with regard to the incision where theyhave to keep the wound dry for the first few weeks before the implant is activated.They should be well aware of the times they have to shave behind the ear of the CIchild in order to fix the speech processor. Nevertheless, the parents should be educated enough to understand theinstructions given by the manufacturers of the CI device as they have mentioned somany cautious situations .The parents should pay attention to follow the giveninstructions in bathing the child, when in sleeping and so on. During these instancesthe parents should be conscious of turning off and removing the external componentof the CI. Nevertheless, those instructions mention about several restricted activities 29
  42. 42. like scuba diving, going near strong magnets etc. Therefore, parents always have tobe very vigilant about their children’s behaviour since they are small. The charging of the battery according to the device is another process whichmost of the parents find it difficult to follow due to various reasons such asstandardized measures of depression, time demands, lack of common sense,illiteracy, anxiety etc. Considering the rehabilitation programmes, it is the parents of these CIchildren who should come in forward to get the necessary steps to be done to theirchildren. But still most of the parents of these children are in problematic state infinding proper teachers for the deaf. They are in trouble in selecting a teacher or a suitable programme for theirchildren since most of them tend to depend on the information they get from theirfriends who have got children with the same deficiency. But these parents do notrealize that this is a surgery which does not give uniform as well as quick resultsand therefore they try to compare their CI children with their friends’ children whichis something shouldn’t be done. Once again it should be the responsibility of thepersonnel in the medical field to educate the parents with CI children, about the timeexpansion that will take to get visible improvement in L1 acquisition after theoperation. Otherwise it is more natural of them to have high hopes about the recoveryof their child’s disability. When we consider parental support, it was observed that the involvement ofmothers was higher to that of fathers in the field of improving L1 acquisition in CIchildren. Moreover the findings showed the level of expectations of these mothers issomewhat high irrespective of the slow rehabilitation process. Therefore they tend toforce the professionals or the teachers for the deaf, regarding the language outcomesof these CI children. It is identified that the cause for these types of behaviours takesplace due to their higher level of stress and high expectations. Thus it is thoroughlysuggested that the parents of these CI children should be rehabilitated beforeanything else if the society intends to make the CI children acquire their L1 moreeffectively. In the matter of handling the CI device it was identified that most of theparents still have not got a proper understanding about its operations, which woulddefinitely influence the efficacy in L1 acquisition of CI children. Although thesepoints are to be considered as minute details, they play a vital role in the efficacy of 30
  43. 43. L1 acquisition since these operations and handling the device properly comes in thebasic position. Even most of the well educated set of parents with CI children , saidthat they still could not follow all the instructions with regard to charging the batteryand with regard to handling the device in various manner in different situations.Therefore, to overcome such issues those parents should be given those instructionsin their mother tongue or there should be a demonstration as to how they couldfollow the instructions easily rather than just making profit by selling the product. Orelse they could print out the instructions in Sinhala and Tamil too and give them tothose parents. Due to the higher level of stress and poor psychological adjustmentsexperienced by the parents of CI children, lack of auditory input takes place whichonce again poses additional threat to optimal development of a CI child. Accordingto this study it was observed that the whole sample of parents were of normal hearingwhereas the children were deaf. Therefore mostly these hearing mothers tend toengage in more controlling, directive actions with their children rather than beingmore likely to respond to their behaviour. Moreover the available evidence throughthis research indicates that although a CI child requires some level of effectivecommunication with the parent, it is not being fulfilled most of the time, mainlydue to the mismatch between the deaf child and the hearing mother. This becomes asignificant barrier throughout the life span of them and as a solution for that, thesemothers seek the help of some professionals which once again does not becomesuccessful since the CI child is not being educated in a stress free environment. Dueto their aggressive violent behaviour they are being controlled in such a mannerwhich once again make them inhibited to grasp their L1. Thereby the CI child tendsto feel these ill treatments and emotionally upset. Therefore not only the parents butalso the caregivers and professionals should be aware of showing them somematernal sensitivity rather than being controlling them all the time although theymisbehave. Furthermore it was identified that the parents tend to avoid talking to their CIchildren as time goes on, since they need much patience and time to tell themeverything in a slow manner. These types of negligence mainly take place due to theresponsibilities of other normal children in the family. Most of the parents with CIchildren pay their fullest attention during the first few months of the surgery but afterthat they fall into a lethargic condition which is something very pathetic from the 31
  44. 44. point of view of the CI children. Therefore this tendency should be eradicated fromour society even by increasing the quality of rehabilitation programmes or bytraining caregivers with full of sensitivity. Otherwise none of us can predict about thefuture of these CI children positively.3.1.2. Parental Support Towards L1 Acquisition Moreover, they have the responsibility to train their children to acquirelanguage too. Therefore, the following tips would be very helpful in teaching their CIchildren at home. Although this guide is there, some of the parents should beeducated by the therapists as well which would appeal according to their level ofeducation. When it comes to parental involvement towards the L1 development in CIchildren, once again this language developmental process could be initially dividedinto two sections. Basically, L1 development of these CI children begins with theaudition and the input of it should be strengthened. Therefore, these parents shouldbe made well aware of these developmental stages. Likewise, the therapists shouldassist these parents and should assign them with specific area of sounds that theyshould work on within a period of a day or two. Then the therapists can observe howfar these CI children have grasped the sounds and move on to another step. Thismethod was observed within the sample set of this thesis and drastic developmentscould be observed.3.1.3..Tips for Auditory – Verbal Therapy at Home The following details of this chapter basically deal with the therapy whichparents at home can handle as they spend more time with their CI children. Thesesmall activities could be done formally and at the same time as informally in order toenhance the CI children grasp their L1 quickly. Although one could see theseactivities as very simple, they affect a lot in L1 acquisition process in CI children.Therefore, these activities should be promoted by the speech therapists andaudiologists apart from their rehabilitation programmes. 32
  45. 45. 3.2.3.1. Tips for formal Auditory – Verbal Therapy lessons at home 1 Children learn through play. 2 If it is not fun for you or your child, they will not cooperate or learn. 3 Make Auditory Verbal Therapy a 24 hour time for teaching. 4 Know your goals for the week so that you can incorporate them in everything you do 5 Sneak short lessons into the daily routine, e.g. 30 seconds for covering one goal " Do you own the pink tooth brush or the blue one" 6 Wait for your childs response signal expectation of an answer by tilting your head and raising an eyebrow. 7 Join in on your childs most favourite game and describe direct action and discuss as you play. 8 Model and expand your childs utterances with additional language and correct grammar if he says “truck" you could reply " Its big truck .Look at the big wheels. I like that big red truck". Instead, we as Sri Lankans can make use of the word “bus” for this because these CI children are not familiar with the word “truck” and further it was identified that these Sri Lankan CI children are not that efficient in producing this retroflex /r/ sound, especially at the very beginning of L1 acquisition. Later they can be made familiar with some added adjectives like /loku/ (big) and then both together as in /loku bas / or /loku bas ekə/ (a big bus). Next they have used some phrases with regard to wheels, which is once again difficult for a Sinhala speaking child to produce /roɖəjə/. Therefore, it is advisable to talk about the length of the bus as /ɖigə/. Accordingly, necessary changes were adapted to suit CI children whose L1 is Sinhala. 9 Reward appropriate behavior with your attention and discourage inappropriate behavior by ignoring it. " Good talking I like the way you said " truck" 10 Read at least 2 books a day – 100 books a day if possible 33
  46. 46. 3.2.3.2. Tips for informal Auditory Verbal Therapy opportunities at home 1 Fold the washing Sorting for young children can be based on using the possessive s" e.g. " These are Daddys Pants. Accordingly, the sample set of CI children were more comfortable when it was said ; /mɑge:/ (mine), because if the words mum’s or dad’s are directly translated into Sinhala they won’t be the same as one syllable. Therefore, these CI children will be confused. It takes some more time with Sinhala speaking CI children than it is with English speaking CI children when considering this point as these children find it difficult to produce possessives like /ɑmmɑge:/ and /t :ttαge:/. 2 Another way of sorting is by colour pattern (checks, stripes etc) Length of sleeves, pant leg etc. 3 Matching pairs put 6 or 8 socks our and ask which ones are the same/ nor the same Ask for a certain sock of the group if an older child. Can I have the sock that has stars around the top? This point basically deals with commands where these CI children are being motivated due to the ease of saying these short phrases such as /maʈə dennə/ (give me). Initially, they will come out with only the action word (/dennə/)- (give) while they later on manage to come out with other words. 4 Wh questions can also be used as ways of sorting .Which pile do these go on? Where do these go? Who wears these socks? Whose socks are these? What are these gloves for? Although, these kinds of questions are proposed for the early development of CI children it was investigated that the CI children in this sample data found it more complex may be due to the language differences. 34
  47. 47. 5 Plurals can be targeted "Put all the socks here. How many hankies are there? When it comes to this type of scenario these CI children will answer giving the number but it is once again debated whether it suits the situation. For example normal Sinhala speaking children will answer that kind of question as /pɑhɑi/ but these CI children will say /pɑhɑ/ which denotes only the number but does not give any implication about the relevance to the situation. This is once again different from English language, because in English it is just /fɑiv/. It is the same as the number unlike in Sinhala. 6 Putting clothes away can be used as a way of following directions" Put these socks in the top drawer" Prepositions such as next to between, beside, behind in the corner, underneath and many more can be used. 7 Directions can be changed from simple to complex put the socks in daddys cupboard in the second drawer. 8 Sabotage makes the session longer “These socks go in the bottom drawer beside the hat isn’t the hat in that drawer? Look in the drawer above that one is the hat in there?Setting the Table 1 Possessives again can be covered" This is Mary’s fork" 2 Simple and compound sentences can be used as directions “Put the fork next to the napkin put the knife and spoon on the right and the fork on the left. 3 In a bottom drawer in the kitchen, have a plastic cup, bowl and plate “Get out the cup. Get out the bowl and the cup. Get out the cup but not the plate." Increase contents of drawer to having a cup, bowl and plate in 3 colours. “Get out the blue plate and the red cup." 4 Napkins can be folded to make rectangles. Squares and triangles. Once again in Sinhala the words which relate the shapes are very complex. Therefore, they are not given much prominence in 35
  48. 48. speech but given in picture matching sessions and object matching sessions. 5 Sabotage again can be used to promote language. E.g. forget to have chairs at the table to put out food on the plate. 6 Have a plastic animal at the table or on the high chair. Give the toy animal something to eat as well as your child. Talk to the toy as you would to the child. As stated above, different changes to these situations were made in order tosuit our Sri Lankan context and Sinhala language.Sitting in the car 1 Singing songs loudly. A tape of preschool songs could be made at music session at preschool next time. Under these they were made to listen to songs with easy words and with sets of repetitive words. 2 Get you older child to tell you which way to go " Turn left over the bridge Go straight ahead turn at the next corner, " Follow their directions and even make a mistake when you know what they say is wrong. They will learn to give specific directions. 3 Time words can be used. Before I start the car, put on your seatbelt while we are in the car we look for traffic signs. After we go to the shop, we will go the petrol station.Waiting at the doctor 1 I spy with my little eye something that people sit on. 2 Im thinking of something that has 4 legs. It is made of wood, it has books on it 3 I’m thinking of something in our kitchen it is white and cold on the inside it has a big door etc. 36
  49. 49. 4 Hum a song "Can you guess what it is?" (Keep it simple at first) 5 Have 5 small stones. Close up hand. “How many stones?" Give a quick look and close up hand again. Vary the number in your hand. 6 Take favourite books to read together. 7 Play whats missing? Take 3 toys from the toy basket cover with a scarf take one away without letting the child see it. 8 Draw shapes on bigger childs back. Guess which shape it is.Taking a Bath and Swimming Language opportunities can be lost at bath time and when swimming, becausethe child cannot wear amplification. Create the language opportunities at a differenttime. Use a bowl of water and wash a dolly as you would do to your child. The childthen will replay those games himself in the bath. 1 Talk about body parts 2 Use action verbs 3 Using verbs 4 Talk about hot/ cold, wet/dry, in/out, under/over, back/front, floating/ sinking etc. Washing the DishesThis takes on new meaning when it is done in a bowl with warm water outside 1 Item selection can be done 2 Following directions 3 Maths concepts can be tested e.g. measuring volume, height, number of animals in a boat before it sinks, etc.1 Although all these parental activities are given according to CI childrenwhose L1 is English, we being Sri Lankans can adapt changes to them in order to suitour culture and language. Therefore, some of the adjustments were made accordingly1 Hear and Say Center 37
  50. 50. as they were used throughout this research. At the same time it is going to be anotherchallenge for our parents as they have to be mindful as to how they are going to helpthese CI children to develop their acquisition level. Nevertheless, through these tipsone could easily realise the work load or the level of commitment of the parents ofCI children in order to make their HI children acquire language more appropriately.Once they become use to these they can automatically engage their CI children inday to day activities by giving them opportunities to expose themselves to language. Therefore, the CI users should be given constant proper guidance in theprocess of localization unlike a normal hearing child .This is also should besupported by parents. And these CI children should be trained to localize soundswhich would later on make them localize alone when they get familiar to that action.For this, parents of CI children should make use of almost all the opportunities intheir surroundings.See - Appendix 3 – Video Clip No.4 - LLT1.f4V (Speech Therapy)13.3 –Rehabilitation Process Furthermore, the rehabilitation process which should take place immediatelyafter the CI also contributes a lot in developing the spoken ability of a CI child. Therehabilitators should always have good rapport not only with the CI children but itshould be emphasised that they should have prompt connections with their parents,audiologists and the E.N.T. surgeons who are responsible of handling each CI child.Nevertheless, these speech therapists should be qualified enough to handle these CIchildren as they should be well aware of certain theories which are connected tolanguage acquisition of normal as well as HI children and the teaching approachesand strategies with relevant to these CI children’s psychology. Therefore, thischapter will also deal with the most appropriate teaching methodology and thestrategies which could be incorporated in teaching CI children. When we talk about the methodology of teaching CI children one couldassume that these methods and activities do not match our Sinhala language and ourculture. But most of the therapists who trained the sample set of CI children made1 http://www.cochlear.com/files/assets/videos/LLT 1.f4v 38
  51. 51. use of these methods very successfully in order to match our children. This gavegreat results in L1 acquisition.3.3.1. Developing listening skills in CI children. The L1 development starts from listening first. Therefore, there were so manystrategies which these therapists used in order to give a proper auditory input in theseCI children. But before all these, CI children were tested by the audiologists for theirproper audition levels after receiving the CI. This is very important for the therapistsin order to develop the L1 perception within these CI children. Therefore, a briefexplanation as to how it is tested is given below.3.3.1.1. Testing Listening Skills Initially, just after activation of the implant these CI children should be testedfor their auditory input. This is done under several medical and physical observationassessments. When we talk about measuring their auditory levels they were checked undera specimen audiogram which is called as speech banana which includes all thepossible speech sounds under several frequencies .This is called the aided hearingtest and here are the following illustrations of them. 39
  52. 52. Figure 3.1 - Model of the aided audiogram Nevertheless, these children are once again tested for their listening levelsthrough their behavioural patterns and through their reactions in several stimuli basedsituations. For example, if they have reached the proper auditory input level theywere able to turn their head towards the direction of the sound. 40
  53. 53. With the help of these results speech therapists decide on the adjustments ofthe implant and if not necessary they will immediately begin speech therapy in orderto make the CI child grasp his or her L1 without any delay. Speech therapists firstobserve the levels of listening skills with implant age. Therefore, it is very essentialto know about the standard abilities of CI children in order to make them achievedifferent stages.3.3.1.2. The Sequential Development of Listening Skills The following table gives an overview of implant-age appropriate listeningskills, but it should be noted that these levels were not the same among every CIchild as most of the CI children demonstrated so many differences in variousperspectives mainly due to other disorders within them apart from the hearingimpairment. Table 3.1 - Cochelear Implant Listening Skills Development Cochelear Implant Listening Skills Development Guide to Rate of progressDevelopment timings are only indicators and will vary according to the number offactors.1-4 weeks after Stage1 of • Awareness of voice switch-on Awareness • Awareness of environmental sounds (able Sound to localize sound) • Detection of ling sounds (a, ee, oo, m, sh, s) • Respond to own name (through listening alone) From 1-3 months : development of discrimination/ identification** of Ling sounds **Discrimination : the ability to perceive difference between two or more speech sounds. Identification : the ability to recognize a sound by repeating, pointing or writing what is heard.2-5 afterMonths Stage 2 Pattern perception and non-language aspects Suprasegmental of speech 41
  54. 54. switch-on Discrimination • Distinguished changes in vocal length and (duration : long & short) Association • Discriminate intensity/ pitch (loud & soft/ high & low) • Perceive difference in intonation/ stress/ rhythm/ rate • Imitating learning to listen sounds (Dog- woof, Cow-moo) • Perceive difference in word length (123+ syllables) • Discriminate sentence length (short phrases)6-9 months Stage 3 Follow developmental steps for listening after Segmental language and speech (refer to Listen, Learn switch-on discrimination & Talk, Cochelear 2003) & Association • Discriminate constant and vowel difference in 1, 2 & 3 syllable words (ball. Apple, dinosaur) • Discriminate between increasingly similar words;  Consonant same, vowel different (boat, bat, bus; cat, coat, car; hat, hit, hot)  Constant different only by manner (house, mouse; bat, mat; far, sat)9-18 Months Stage 4 Identify: post- Identification • 1 keyword in context, with & without implant suprasegmentals • 2 key words in context, in one sentence • 3 key words in context, in one sentence • 4+ key words in context, in one sentence18+ Months Stage 5 • Advanced vocabulary development post- Progressing & (expand categories, abstracts) implant Comprehension • Increase word play association through listening • Answer simple questions (where, what, who) • Understand increasingly complex sentences with 3+ elements • Listen to short paragraphs and answer simple questions • Answer complex questions (how, why, what, next) • Listen to longer paragraphs and answer complex questions • Sequence with and without visual support like pictures and cards 42
  55. 55. • Increase cognitive language skills (more complexity) • Follow conversation with familiar topic • Follow open-ended conversation (topic unknown; unfamiliar speaker)1 With some kind of understanding about these stages the speech therapistsinvolve in teaching listening with the help of parents. Therefore, the followingstrategies are being followed.3.3.1.3. Teaching Techniques and strategies to develop listening skills • Be within hearing range. Sit on the childs better ear. Ensure you are speaking on a level opposite to his/ her hearing aid. • Start with easy to hear sounds. • Have extensive experience through play • Have high expectations expect that the child will hear • Parents must take part in the therapy sessions so that they learn what to do and can also be used as models for example, stimulus response activities it is necessary to have two adults when teaching the child the one making the sound must not respond; turn taking skills can be developed by using parents as models. • Auditory input first the spoken input is given before the toy / item is seen or before the toy moves. • Encourage children to vocalize before the toy moves or before they have their turn. • If the child vocalizes when working with toys and associated sounds, reward him/her by giving him/her the toy and then repeat the sound again to reinforce. • Have lots of repetition built into the game/activity. • Parents need to be given ideas for reinforcing in home setting so that meaningful interaction occurs.1 Adapted from Shepherd Centre notes, Immediate AV course 2003 and from Childrenss Hospital,Oakland, Rate of Progress – Hear now And always CochlearTM 43
  56. 56. • Do a range of activities in a session to give parents a variety of ideas but let them know that they can spend a lot time on the one activity when playing at home.• Younger children cant play and listen. They can be rewarded after they have listened by playing with the toys. When they are older and good listeners they may be able to do both.• Integrate cognition – Even though a childs language and speech may be delayed, she can be challenged cognitively.• A barrage of auditory information is necessary before the child sees the object. Present the object in an interesting way so that there is the opportunity for a lot of repetition.• Allow time for the child to respond it is necessary to allow processing time• Change suprasegmental features – this makes the input more auditory available.• Move closer to the microphone and speak softly if there is difficulty with a particular sound not too close however and too close however and remember to use a quieter voice.• Dont have distracting noises when talking e.g. noisy toy.• Dont test very young children check incidentally whether meanings are being associated and identification skills are developing.• Achieve goals through play – However in the formal lessons it will be contrived play.• Have short term and long term goals.• Choose age and stage appropriate materials and activities which are interesting. Challenging and meaningful.• Establish age appropriate expectations for behaviors expect compliance.• Always be mindful of extending the child go one step further (Greater M.I.U. etc.)• Be mindful of extending both receptive and expressive skills.• Capture the childs attention.• Provide plenty of opportunity for the child to respond and expect him/her to respond to communication attempts – this is necessary to build up the ability 44

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