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:Approximately 90% of children with hearing loss develop in homes where spoken language is the basis for communication.For most of these children, hearing aids and cochlear implants can provide hearing that is good enough to play its natural role in development.Nevertheless, there are deficits of assisted hearing that need to be offset by intervention.For the very young child, that means helping parents provide an enhanced learning environmentThat environment cannot focus only on hearing and speaking but must include cognition, both general and social.
2. For most of these children, hearing aids and cochlear implants can provide hearing that is good enough to play its natural role in development.
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
That environment cannot focus only on hearing and speaking . Speech is only a medium for language Language itself relates to what the child knows – that is cognition The need for, and use of language, is based on what people know about themselves and others – that is 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. - physical, social environment, and language The physical environment consists of objects, events, their properties, and the many relationships among these – 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 involving people and its relationships to the physical and social worldsThese 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 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 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 development and, ultimately, 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.
Note that I refer, not to teaching but to learning. 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 role of the teacher is to provide an environment and experience that promote learning.Fortunately our best ally is the child. Children are driven to learn about, 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 continue into adult life and are best expressed in the scientist.
Scientific method begins with observation. Theories represents our 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 uses 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 – all the time including relevant 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 their relationships.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 a occasion, most of the direct interaction will be between parent and child. The interventionists 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 reach the stage of acceptance the process of indirect intervention begins with :Observation and evaluation of the child, the parents, and their interactive styleProviding 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, and the many strengths of them and their child.Demonstration and coaching in effective ways to interact with and communicate with their child that will enhance cognitive, social cognitive, and language development.Empowering them as they come 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. 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, teachers. Disagreements and miscommunications within the intervention team work to the detriment of the child.
As far as direct intervention with the child, whether by therapist or parent, it is all about 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.
Here, in the simple example of playing with a hammering toy,the child is moving and experiencing the results through the senses of feeling, seeing, and hearing. The associations among them are promoting sensori-motor development and the 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, and words and experience also promote language development.
All the activities of daily living – feeding, toileting, dressing, bathing – provide opportunities for cognition/language associations, as do play activities whether 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.
I have stressed the importance of cognition and social cognition for the development of language. Our immediate concern is language in its spoken form as the child develops the interdependent skills of speech perception and speech production.At each level, however there is positive feedback.In other words, as skills and knowledge emerge, they serve to strengthen their own causes.As the child uses her speech skills, she refines and improves the language represented by the speech.But the most important feedback comes when the child uses language to promote cognitive development. It is this feedback effect that accounts for the dramatic, accelerated, growth of cognition and language between the ages of 2 and 4 years.
The immediate effect of a hearing loss is a reduced ability to perceive speech. But because of these interconnections, this sensory deficit can affect everything else: speech production, language development and cognitive development.
By optimizing aided or implanted hearing, and enhancing nurture, the negative consequences of the hearing loss can be reduced or, even avoided. There are, however, two cautions to consider:Assisted hearing capacity differs from child to child. The skilled interventionist recognizes when a child receives only limited help from aids or implants and modifies intervention strategies accordingly.Around 30 to 40 percent of children with hearing loss also have deficits in other areas. These deficits increase the negative consequences of the hearing loss. General cognition suffers, for example, in children with reduced intellectual capacity. And social cognition suffers in children on the autism spectrum. When the hearing loss is accompanied by other deficits, intervention generally needs to be more intense and, possibly, different.
These then, are my messages.The first step in management is to provide the best possible hearing capacity.With modern technology, early identification, and early intervention, best hearing capacity usually means that hearing is good enough to play its natural role in development. But enhanced nurture is needed to compensate for inevitable deficits of capacity. The amount of enhancement needed differs from child to child and family to family. Intervention must emphasize cognitive development – because this is the basis for language, regardless of modality.When the child’s needs and natural abilities are combined with hearing, language emerges in its spoken form.The pediatric audiologist assesses hearing capacity and provides appropriate assistance.The early interventionist assesses both child and family and provides guidance and empowerment to the parents.For best results, both must assess the outcome of their own and each other’s efforts and communicate with each other. Developing age appropriate spoken language in children with hearing loss is a team activity. One final comment.The principles and approach advocated here are equally appropriate for the normallydeveloping child without hearing loss. It was your own Maria Montessori who worked toenhance nurture for developmentally disabled children and then realized the potential benefitsof applying the same methods with normally developing children.We must remember, however, that the normally developing child can usually learn incidentally withoutenhanced nurture. It is as if he learns from the crumbs that fall from the table. But the childwith a hearing loss needs enhanced nurture. He or she must be seated at the table.
Some readingsLillard, P. (1997). Montessori in the classroom: A teacher’s account of how children really learn. New York, NY: Schocken Books.Boothroyd, A. (1998). Childhood deafness: the complexities of management. In: A.K. Lalwani and K.M. Grundfast (Eds.), Pediatric Otol Neurol. Chapter 50, pp 697-705. Philadelphia, Lippincott.Gopnik, A., Meltzoff, A., & Kuhl, P. (1999). The scientist in the crib. New York, NY: William Morrow & Company.Boothroyd A (2000). Management of hearing loss in children: no simple solutions. In: Seewald RC (Ed). A Sound Foundation through Early Amplification. Phonak AG.English, K. M. (2002). Counseling children with hearing impairment and their families. Boston, MA: Allyn & Bacon.Hirsh-Pasek,, K., & Golinkoff, R. (2003.) Einstein never used flash cards. New York, NY: Rodale, Inc. Gutek, G. (Ed.). (2004). The Montessori method. Lanham, MD: Rowman & Littlefield. Boothroyd, A. (2004). Measuring auditory speech perception capacity in very young children. In Miyamoto, R. (Ed.). Cochlear Implants: Proceedings of the 8th International Cochlear Implant Conference. International Congress Series 1273. pp 292-295. Netherlands: Elsevier.Luterman, D. (2006). Children with hearing loss: A family guide. Sedona, AZ: Auricle Ink Publishers.Luterman, D. (2008). Counseling persons with communication disorders, and their families (5th ed.). Boston, MA: Little Brown.Waldman, D. & Roush, J. (2009) Your child’s hearing loss: A guide for parents. San Diego, CA: Plural Publishing.Rosner, J. (2010). If a tree falls: A family's quest to hear and be heard. New York, NY: Feminist Press.Cole, E., & Flexer, C. (2011). Children with hearing loss: Developing, listening, and talking. San Diego, CA: Plural Publishing.Boothroyd, A and Gatty, J. (2012). The Deaf Child in a Hearing Family: Nurturing development. Plural Publishing, San Diego.
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 Director: Edoardo Arslan University of Padua
Acknowledgements• Dr. Janice Gatty: Colleague and co-author• Office of development, the Clarke Schools for the Deaf: provided many pictures
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