Summary of the AVI Conference
March 1, 1997, New Providence, New Jersey
Spoken Language Development For Children With Hearing Impairment
Learning and teaching spoken language:
Today's technology allows early detection of a hearing loss and early intervention. This was not possible 10 years ago and therefore we are dealing with new dimensions of teaching prelingually deaf children how to become oral in an oral world. The technology is not an aid any longer but has become a driving force of speech and language therapy. With the help of appropriate hearing aids, amplification in school and home with, for instance, a FM system or a Loop system (it only costs $20.00 to "loop" your house) almost every deaf and hard of hearing child will be able to hear spoken language. With appropriate therapy they will be able to learn to speak fluently.
Learning to listen requires more information than listening after meaning has been established. To visualize this statement envision a cup of coffee spilling over a manuscript and obliterating most of the words. If you know what the manuscript is about, you will be perfectly able to understand the sense of the mostly obliterated text. But this manuscript would be very inappropriate to teach a child to read.
Informal teaching should therefore include: The context- based spoken language, the perception of the message, the refinement of the dialogue and -most important- the perception of meaning. The area in the brain involved in phonological processing (Broca's area) and the "meaning area" are distinct from each other. The Broca's area, which is often effected by a stroke, speech-, and learning disability is located in the inferior frontal gyrus and functions like a computer chip. The Broca's area is a phonological processor that sends information to the "meaning area" in the brain. Stimulation of the Broca's area and its role in feeding the meaning area are crucial for speech and language development. Analysis and comparison of female and male brains has shown that the female brain has two Boca's areas, whereas the male has one. This might explain the ability and ease of many female students to learn foreign languages.
Without the establishment of meaning of the spoken language, intelligible speech will not develop. A study conducted by Gallaudet University has shown that less than 10 % of the deaf population has intelligible speech. It is of great importance that opportunities are created for the child, even at a very young age, to learn the significance of events in everyday life and the language that relates to them. Learning must become an integral part of everyday family life, not something fostered mainly by an adult's imposition of pre-planned lessons. Teaching how to voice a certain sound using sophisticated computer programs do not teach meaning. The emphasis of the voice determines the meaning of a sentence. Meaningful spoken language can be associated with any activity but to be meaningful it must be used under conditions that permit it to be optimally perceived. Parents and teachers should talk clearly at a normal conversational level and at close range, talk about everyday routine situations, talk about objects and events that relate to shared experiences, look for the best possible level of comprehension, even for the earliest stages, provide abundant context thus to endow utterances with meaning, talk in complete sentences, follow their child's focus of attention, allow sufficient time for their child to respond, be comfortable with the use of body language, shift responsibility for speech intelligibility to their children as they grow and accept that they have the primary responsibility for their children's communicative competence.
Auditory /Verbal Development, where to begin:
Children can actually be taught to become deaf, they will tune out due to over stimulation or a constantly talking person, this also needs also to be considered when a FM system is funneling constant and irrelevant speech into a child's ear. Sound interesting when you talk, balance talking with quiet. Singing to the child creates a wonderful listening environment. Talk about things before you show them. As soon as the child sees the item, he will most likely not listen any longer. Get the attention with acoustic highlighting and changes in the intonation pattern. Define word boundaries clearly. The sentence "go put your shoes on" could be understood by the child as "Gop utyush uzon", a sentence without meaning. By using contextual clues and rephrasing, meaning can be established and the sentence can be understood. Followed by the words "we will go outside, you will need your shoes", the word boundaries for "shoes", "you" and "go" are clearly defined and therefore the sentence "go put your shoes on" will be understood if repeated. Even with the best amplification, the hearing impaired child will miss some pieces of spoken conversation. It is the role of the speech therapist, to teach how to fill in the gaps.
Learning and Teaching:
The responsibility of the speech / language pathologist is
The aspects of discourse should include: conversation, narration, questions, explanations (specify how...) and descriptions (specify physical features, spatial and other relationships).
Diagnosis and Fitting:
The gain of a hearing aid specifies the amount of amplification gained due to the aid. A hearing loss of 90dB (unaided) and 30dB (aided) in a given frequency shows the impact of the gain (60dB) of the hearing aid. Today's technology provides many different kinds of extremely good hearing aids. An appropriate hearing aid, appropriately adjusted to the child's hearing loss should give a gain of 60dB across all the frequencies. An audiogram that shows a gain of 40dB across the frequencies is not acceptable. A better suited adjustment and/ or hearing aid needs to be fitted. Nasal speech of many deaf and hard of hearing oral adults is the result of improper amplification of certain frequencies. The five Ling sounds: m, ee, ah, oo, sh and ss reflect different frequencies of speech. All of the Ling sounds should be properly identified with the optimal amplification. In some cases however, one or more of the Ling sounds cannot be heard even with the best amplification. In those cases, a cochlear implant will be discussed. Auditory- verbal therapy will not be successful if one or more of the 6 Ling sounds cannot be identified.
Often, earmolds decrease the quality of sound because the tube is jammed into the earmold which leads to a decrease in diameter of the tube. A good earmold consists of a tube that has the same diameter on the hearing aid side as on the earmold side. Earwax clogging part of the tube also leads to a decrease in sound quality. A specially designed earmold that has a wider tube at the earmold side than the hearing aid side (CFA bore) can effectively enhance the quality of an "s" sound. For this purpose a #16 tubing is inserted into the #13 tubing to create a smaller diameter at the hearing aid side and a wider (3 mm) diameter at the earmold side.
Auditory-verbal therapy and the Cochlear Implant:
There are a few differences in speech / language therapy with the Cochlear Implant user. Many of the Cochlear Implant children are able to hear sounds and speech in the 35dB range or above. The improper identification and production of the 6 Ling sounds might reflect the need for a new map of the speech processor rather than a need for improved listening and speech production skills. Auditory misperception like cat/bat are common. These misperceptions should be corrected but should not be aim of intense therapy. They will most likely disappear with a new map of the speech processor. Along the same lines, speech therapy does not need to target high frequencies. Those frequencies can be heard by the CI user. The speech / language pathologist should be able to predict when the child needs a new map by looking at and comparing patterns of speech perception. Furthermore the speech/ language pathologist has to watch for tolerance problems, levels of discomfort of certain sounds. Close work with the mapping Audiologist is required. An older child with little or no hearing who had already established other ways of communication through sign language or visual aids before he was implanted, is more difficult to work with. The child has to learn to rely on his "new" hearing rather than on visual clues. The speech therapist needs to develop confidence of the child as a listener. The search for appropriate material becomes crucial. Baby activities will not work with a 9 year old child. A young child, implanted at an early age will go through normal speech development. The level of therapy should incorporate the language level of the child but should target one language level above the present performance of the child to stimulate learning.
One important part in formulating the IEP is to identify who is responsible for what area.
Important issues to be addressed by the speech therapist / itinerate teacher are the learning environment, the child and the team.
The itinerate teacher needs to address modifications to be made to the classroom acoustics and the teachers style.
For hearing children the signal (voice of the teacher) to noise (background) ratio has to be +6dB for the teachers voice to be heard. A hearing impaired child needs the teachers voice to be +10-20dB above the background noise to be able to hear the teacher. Preferential seating and having the teacher speaking from a close distance in the classroom only results in a gain of +4dB. The background noise reduction (carpeting, tennis balls under chairs, wall modification) become an important issue as well as the use of a FM system.
The teacher needs to get in-service about crowd control and the proper use of the FM system. A FM system that is constantly on, can harm more than it does good if it is not used appropriately. The teacher needs to know that the FM should be "off" and only be turned "on" when the teacher is talking to the entire class. The teacher needs to get good in-servicing for the FM system. A designated person in the school needs to monitor the system and check it every morning with a stethoscope. The teacher needs to understand the child's need of speechreading. General teaching should include: contextual information, visual clues, consistent routines, transitions and changes of routines need to be told to the child, topic changes need to be clearly defined, new vocabulary needs to be written on the board, the teacher needs to pause between sentences or subjects. The itinerate teacher helps with getting scripts of film strips , captioned video tapes.
Concentrated listening over many hours throughout the day leads to auditory fatigue. The child can greatly benefit from "down time", sitting outside for a couple of minutes. The child will have vocabulary and language gaps, pre-teaching of academic subjects is important. It is important to know who will do the pre-teaching and how to go about that (need to get lesson plan in advance). In group discussions, the children need to be called by name, rephrase what the children say. Get a picture of the class and learn the names of all the children during the first week of school. The teachers should be aware of strategies to make the hearing impaired child less special. "It is too noisy in here" addresses the entire class but "Please be quiet, because Betty can't hear" will isolate the hearing impaired child. The hearing impaired child has reduced distance learning, passive learning, is often overwhelmed, has often a lack of social language and social skills. All these issues will need to be addressed, entered in the IEP and defined who is responsible to teach what. The child needs to learn and experience confidence. Often not understanding becomes very comfortable and the child likes to avoid learning situations. The behavior problem becomes an issue for the hearing impaired child. It might lack risk taking ability and might become "rigid". Strategies need to be developed by the itinerate teacher and shared with the team. Application in the classroom and outside of the classroom need to be discussed.
The role of the itinerate teacher /speech teacher is to coordinate between team members. Often the team members don't know what to do. Arrangements have to be made to have feed-back on a weekly basis ( a 10 min telephone conversation might be enough). The itinerate teachers role is to support the teacher, show her that the team will support her. In-service training on how a hearing loss affects learning needs to be done during the first week of school or even better, before school starts. The child needs pre-teaching and repetition of vocabulary, the team needs to be provided a curriculum. The teacher will need material and visual aids to support the curriculum.
Speech therapy: Consonant production:
One of the most dramatic demonstrations was on how to teach a "s" sound in 2 min., a "k" sound in 2 min. and a "g" sound in 2 min. For further information, read Daniel Ling's "Foundations Of Spoken Language For Hearing-impaired Children".
Daniel Ling is the author of several books available through the Listen-Up Bookstore.