Katie Brennan, MS, CCC-SLP
When a child is diagnosed with hearing loss, early intervention strategies are instrumental in laying the foundation for language development. The professionals at the Boys Town National Research Hospital’s Center for Childhood Deafness (CCD) consider the entire range of communication approaches (i.e., fully auditory through fully visual) when tailoring a program to meet the individual needs of each child and family. This individualized approach is designed to support each child’s communication, auditory, social-emotional and educational development. Among the services offered to families of children with hearing loss are aural (re)habilitation (“listening sessions”), speech-language evaluations, parent-infant services, preschool, multidisciplinary evaluations, Augmentative and Alternative Communication assessments, cochlear implant candidacy evaluations and programming, and parent education opportunities. Preschool programming includes a dual track early childhood approach providing classes emphasizing listening and spoken language as well as classes that provide sign-supported spoken language development. Listening sessions are also offered to adults with hearing loss.
Speech-Language Evaluations: Children are often referred for speech-language evaluations by audiologists, school SLPs, primary care physicians, mental health professionals, parents and/or other professionals. The basic components of a speech-language evaluation at the CCD are the same as any other thorough speech-language evaluation: semantics, syntax, phonology, morphology, pragmatics and an oral-motor exam. However, when a child presents with hearing loss, another objective is to assess the child’s auditory development and to determine goals for enhancing the child’s auditory skills to support spoken language learning.
Auditory skills which may be evaluated include detection, identification, auditory memory, and auditory comprehension. The SLPs at the CCD will analyze test responses and results in an effort to understand the impact of hearing loss on speech and language development. For example, when a child is not yet using a final “s” to mark plurals or possessives, the SLP probes whether the child is able to hear that “s” sound with his current amplification settings. Articulation skills can be analyzed in a similar fashion taking care to determine if sound errors are truly errors in production or in perception of acoustically similar sounds. A child may be substituting /t/ for /k/ not because of a traditional articulation error but because /t/ and /k/ sound the same to the child. Numerous speech perception tests are available and require specialized training in order to implement. Collaboration with a child’s audiologist is also paramount to optimizing therapeutic and educational outcomes. Children with hearing loss can have additional language learning challenges which are not related solely to the hearing loss. In fact, it is estimated that 35 to 40 percent of children with hearing loss have additional disabilities which adds to the challenge of obtaining clear results for families (Gallaudet Research Institute, 2008).
Regular follow-up speech-language evaluations are important components of the educational and therapeutic plans for children with hearing loss who are developing auditory skills. Annual speech-language evaluations allow therapists to monitor rates of progress and, as a result, make recommendations for changes in educational programming or communication approaches when necessary.
Aural Habilitation (Listening Sessions): Following the fitting of hearing aids and/or cochlear implants, participation in listening sessions is recommended to families in order to support the development of their child’s auditory skills. SLPs at the CCD set goals using auditory skills development guides such as the Auditory Skills Hierarchy developed by Erber (1982), the Cottage Acquisition Scales for Listening, Language and Speech (Wilkes, 1999), and the Targets for Auditory/Verbal Learning (Cole & Flexer, 2011) in conjunction with typical speech and language development models for children with normal hearing. Listening sessions focus on building a foundation of listening experience in order to support the development of more advanced auditory, speech and language skills.
Listening sessions at the CCD have a strong caregiver participation component which places the SLP in a coaching role. A parent coaching model may differ from the direct interventionist approach used in traditional training programs. Since listening happens all day long, caregiver participation in listening sessions is crucial. During listening sessions, caregivers have opportunities to observe and practice strategies for enhancing auditory learning opportunities throughout the child’s entire day.
Just as babies born with normal hearing have months of exposure to sounds and language and time to experiment with using their voices while babbling, children with hearing loss who obtain access to sound at a later age need to have these same opportunities. Some children who get cochlear implants have had no prior experience with sound and are considered beginning listeners. A new cochlear implant user is just beginning to gain auditory experience and needs to begin in the early stages of the auditory skills hierarchy (i.e., detection, discrimination, identification) and build toward more advanced comprehension level auditory skills.
Aural habilitation takes an auditory-based approach to intervention. When children have additional areas of concern, such as apraxia or intellectual disabilities, other approaches may be integrated. Aural habilitation focuses on building foundational skills while traditional speech-language therapy usually addresses the individual skills which are not present or may be delayed, such as working with a two-year-old child who is not producing a /p/ sound. A traditional approach may target the production of a /p/, while aural habilitation will work toward building an auditory foundation for the target. Aural habilitation focuses on developing speech skills through listening. Using listening to shape speech targets with children with hearing loss may seem counterintuitive, but children with appropriate access to sound need to develop their auditory feedback loops to self-monitor. Visual and tactile cues may be used but are a secondary support in modifying speech.
Intervention with a child with hearing loss is a team effort. All the adults and environments in that child’s life must support the parents’ goals for their child. Coordinating a number of professionals is not always an easy task. Communication amongst team members is important to support carryover of skills as well as maintaining consistent expectations. Due to the low incidence of hearing loss, many professionals do not have experience working with children with hearing loss. The role of the SLP at CCD includes providing support to other professionals working with children with hearing loss.
A challenge related to working as a team is illustrated in this story from an SLP at CCD: The parents of a preschooler were motivated to have their daughter develop her spoken language, but they had difficulty with keeping her cochlear implant speech processor on consistently, both at home and during her hours at daycare. The child care workers were not as familiar with or comfortable with the technology. After the annual IEP meeting, the parents were more committed than ever to keep her speech processor on at all times. Eventually, with support from the SLP to the day care workers, the child became accustomed to wearing her speech processor consistently. Once consistent device use was established, the child began making amazing progress in her spoken language development.
Other challenges encountered when providing listening sessions for families include working with families whose first language is not English, families with limited resources for traveling to center-based intervention, literacy level of family members, and other disabilities a child may have. The state of Nebraska has a large rural population and many families that receive services at the CCD live in these rural areas. The therapists at CCD work with professionals in rural areas to support children who are not able to travel to the CCD on a regular basis for follow-up. As technology advances and changes, therapists must know how to troubleshoot older and newer models of hearing aids, cochlear implant speech processors and FM systems.
Follow-up for families with children with hearing loss can result in the development of strong relationships with their SLP. SLPs see babies grow week to week in all areas of development. One SLP at the CCD had a child take his very first steps during one of their listening sessions. Another young girl who had just started combining words came into a listening session saying, “baby tummy” because her mother was expecting another baby. Her mom said there were no more secrets at their house!
Outreach and Continuing Education Services: As technology quickly changes and advances, the world of deaf education is changing. Boys Town offers continuing education opportunities to fit the needs of practicing clinicians. The CCD offers a variety of continuing education opportunities including online courses, interactive study groups (e.g., speech perception, student assessments), and more comprehensive consultations for school programs. Courses address a variety of issues related to hearing loss and can be attended on-site or accessed remotely through distance learning technology. Courses are presented by a variety of professionals including audiologists, speech-language pathologists, educators, researchers, physicians and parents.
To learn about current best practices in the education of children with hearing loss and to get support implementing those practices, contact the Auditory Consultant Resource Network at Boys Town. Consultants provide onsite training and program development that capitalizes on effective hearing technology, innovative educational methodology, sound leadership models and state-of-the-art distance technology. Consultants provide services ranging from individual professional coaching to comprehensive school district consultation. School district consultations assist in examining current educational practices, staff training needs with a focus on developing optimal outcomes for children with hearing loss.
Since the opening of Boys Town National Research Hospital in Omaha, Nebraska in 1977, the hospital has been internationally recognized as a leader in clinical and research programs focusing on childhood deafness, and related communication disorders. The Center for Childhood Deafness (CCD) at Boys Town Hospital provides services for children and adults with hearing loss and their families, federally funded research programs, and state of the art technologies to support outreach/dissemination efforts including DVD and website development, distance education, continuing education opportunities for professionals and families, and outreach services for educational agencies.
Cole, E. & Flexer, C. (2011) Children with Hearing Loss: Developing Listening and Talking, Birth to Six. San Diego, CA: Plural Publishing, Inc.
Erber, N. (1982). Auditory Training. Washington D.C.: AG Bell Publications.
Gallaudet Research Institute (November 2008).Regional and National Summary Report of Data from the 2007-08 Annual Survey of Deaf and Hard of Hearing Children and Youth. Washington, DC: GRI, Gallaudet University.
Wilkes, E. (1999). Cottage Acquisition Scales for Listening, Language and Speech. San Antonio: Sunshine Cottage School for Deaf Children.