deafness learn as we go

snowball

Delayed and degraded exposure to spoken language leads to:  1. Incomplete phonological representations
2. Delayed speech and language development - speech is difficult to understand
3. Weak vocabulary and syntax leads to difficulties with comprehension
4. Difficulties acquiring pragmatic and social skills leads to social isolation
5. Weak oral language skills lead to delayed literacy low academic attainment and unemployment

Language stimulates brain development

early stimulation is crucial to prevent neural degeneration. hearing plays a vital role in developing spoken language while speech and sign language stimulate corresponding language areas in the brain. research indicates better outcomes for deaf children identified and aided before 6 months of age

access to first language

Delayed and/or restricted access to a first (spoken or sign) language leads to language deprivation.
Use of sign language increasingly advocated by deaf people, although evidence that the same levels of development can be achieved by children in hearing families is currently limited

Period before cochlear implantation is crucial. Some research shows advantages for use of sign language (L1) before cochlear implantation to facilitate spoken language (L2) development.

1-3-6 model/1-2-3 mode

Identification of deafness at 1 month

Diagnostic audiological assessment at 3m (2m)

Early intervention at 6m (3m)

sign as first langauge

Research shows that children in deaf families have early and fluent access to a first language in sign, and that sign language development parallels acquisition of spoken languages: Manual babbling or ‘mabbling’

Slight advantage for first signs

Sign combinations appear when hearing children combine spoken words

Overgeneralisations

Phonological simplifications

access to sign + hearing

Insufficient evidence to determine whether a single approach is suitable for all children.

Sign language allows access to meaning, not always gained through use of oral language alone

Use of spoken language and signing together enable children to access more vocabulary and grammar than either alone

Importance of early identification and use of effective amplification

Influence of a range of child and family specific factors on communication choice and outcomes

Aims of early support

Empower parents by providing families with information and support within a co-ordinated team and with positive attitudes

Establish early and effective communication within the family

Develop and monitor child’s communication skills in the most appropriate mode (including diagnosis of additional disabilities)

Maximise child’s use of residual hearing & speech using amplification optimally

What information do parents need?

Professionals and services: 

•Professionals they will meet in health, education, social services

•Voluntary organisations

•Financial help

Hearing:

•Hearing testing

•Hearing aids & cochlear implants

•Optimising the listening environment

Communication and ways to support development 

Education options

Co-ordinated Professionals

Key professionals in local and/or hospital teams:

Teacher of the Deaf (peripatetic TOD)

SLT

Audiologists

Doctors

Deaf staff (where available)

Voluntary organisations, e.g. NDCS

Peripatetic TOD

Explaining about the hearing loss, HAs,CIs,

Environmental adaptations

Preparing for school
Parent support

Information

 Communication modes 

Monitoring HA use

Role of SLT

Parent support

Information

Communication modes 

Monitoring HA use
Facilitating interaction

Advising on and modelling language input

Monitoring development

Developing listening skills for speech

Deaf staff

May be employed by education, social services or charitable bodies (NDCS, RNID) to work with families

Role:

Promote a positive deaf adult role model

Provide information about Deaf culture

Facilitate interaction

Model and teach signed communication

Help parents accept their child’s deafness

Parent-Child Interaction therapy (aka Video Interaction Guidance)

Video parent interacting with child

Parents observe video with therapist and evaluate their own interaction

Focus on what parent is doing well, not only what they are failing to do

Change one thing at a time

Use video for before/after measures

Making communication accessible

Gaining attention/eye contact

Moving into child’s line of vision

Use of facial expression & gesture

Games, e.g. peek-a-boo

Tapping (not successful in first year)

Developing joint attention

Content of parental language

•Move sign within child’s focus of attention

•Sign on child’s body

•Use of slow, large, repetitive signs
•Less language, but more accessible

•Fewer questions, more naming or commenting

•Simple language at the child’s level

•Use of mental state language

Tools for monitoring child’s communication skills

Mac arthur CDI
ling 6 sound test
NDCS

NDCS

Tracks areas of development at risk from deafness, within the context of the whole child from 0-3 years: 

◦Communication

◦Listening & attending

◦Vocalising

◦Social & emotional development

◦Play

◦Physical development

 Pointers to encourage development

MacArthur CDI

 Monitoring early lexical development: Outside things & places to go

 People

 Games and routines

 Action words

 Words about time

 Descriptive words

 Pronouns

 Prepositions & locations

 Quantifiers

Ling 6 Sound Test

A functional check of sound awareness/discrimination across the speech spectrum (250-8000Hz) with amplification device

Present 6 speech sounds individually (auditory only)

Maintain a consistent loudness and distance

Look for a response (awareness) or repetition (discrimination)

Profile of Actual Speech Skills

Designed to measure vocal changes in the early months after cochlear implantation

Based on a 6 minute video sample of spontaneous speech taken in a play situation with child’s caregiver/parent

Vocalisations are classified; frequency of occurrence of each category is calculated

Periodic reassessment enables monitoring of change

PASS Category/ Description

Speech: Recognisable or reasonable approximations of phonemes of English. Could be transcribed using broad phonetic transcriptions

Non-speech: Sounds that did not represent speech at all, including lip smacking, growling, sighs, raspberries, ingressive airstreams and tongue clicks. These were sounds that may have occurred in other languages, but were not considered to be a part of the English phonetic inventory

Speech-like: All other sounds that did not fit into speech or non-speech categories were classified as speech-like. These utterances had a vocalic or nasal quality or consisted of vocalisations produced on a glottal fry

Other: This category denotes articulatory behaviours that should be eliminated from the child’s repertoire, including exaggerated jaw or lip movements without phonation

Developing pre-speech skills

Encourage parents to:

Copy child's vocalisations and babbling

Play with noisy toys & voice activated toys

Verbalise noises, e.g. animal sounds (vowel based,

e.g. moo/baa), vehicle noises (e.g. vrrrm)

Use varied intonation patterns, e.g. “Wheeee!” down the slide, “Up we go!”, counting stairs, “Oh dear!”

Sing – anticipation rhymes (Round & round the garden), action rhymes (Wheels on the bus)

Look at books

Significant factors for optimising outcomes

Children do well where:

Programmes are parent-centred (limited direct intervention with infants)

Parent–professional partnership

Strong counselling component

Parents fully informed

Access to range of role models

Careful monitoring of child’s progress: vocalisations & consonant production; expressive language development

Critical factors in the development of a healthy identity

Acceptance by family, professionals and peers in the early school years

Educational experience

School type, engagement, interaction with peer group

Students in mainstream settings may not develop close relationships with hearing peers, particularly out of school

Availability of a critical mass of Deaf peers with whom to identify and socialise, in and/or out of school

Encounters with Deaf role models

Consequences of deafness: mental health

Risk of abuse is is high for deaf children and adults

Twice as many experience mental health problems as in the general population

Mental health problems are linked to communication problems

Twice as many deaf adults experience anxiety and depression, and quality of life in older adults is associated with sensory decline

Speech perception

an audiovisual process: Hearing aids and cochlear implants have benefits and limitations

Hearing and seeing the speaker supports speech perception

We call this speechreading (lipreading)
Only 30% speech can be accessed through silent speechreading
speechreading alongside residual hearing maximises speech perception

Advantages of seeing the speaker

For a hearing person in a noisy environment, seeing the speaker:

Is equivalent to a 15dB increase in the signal to noise ratio

Keeps attention on the speech source

Is particularly helpful when material is difficult to understand (e.g. accents, foreign languages) or when listening conditions are poor

Sign language interpreters

1 or 2 interpreters?

Plan breaks (every 20-30 mins)

Provide preparation materials

Using interpreters:

SL interpreters are the ‘voice’ of deaf people but are usually

impartial

Remember to refer to the deaf person in the 1st person

F2F session: look at the deaf person NOT the interpreter

Enforce rules: take turns, allow for time lag

Online: consider which view and who to pin (Zoom)

Mild hearing loss

may use a hearing aid or find speech reading useful, particularly in noisy situations. Speech may or may not be affected

Moderate hearing loss

may have difficulty in hearing what is said without a hearing aid. Many will speech read. Speech may be affected. Some may use sign language or need other communication support

Severe hearing loss

may have difficulty in following what is being said even with hearing aids. Most will speech read and some will use sign language or need other communication support. Speech is affected. May use cochlear implant

Profound hearing loss

hearing aids may be of little benefit for communication. Most will speech read and will need some form of communication support. BSL may be their first or preferred language. Speech is affected. May use cochlear implant

When is a hearing loss significant

A hearing level greater than 40dB

Remember that age at onset is significant – adults compensate for some element of hearing loss

In children “any degree of loss which affects language development” as children require greater speech redundancy during the critical period for language acquisition

Working with clients who use amplification devices

Individuals vary in their response to amplification - depends on features of the loss and fit/use of amplification…always request an aided audiogram, more useful for planning speech intervention than an unaided audiogram

Amplification is only useful if it is working…always check amplification is functioning

Amplification devices work best in a good listening environments…always ensure acoustic environment is optimal

Ask the individual about their experience or observe their behaviour

Glue ear: testing issues

Toddlers are difficult to test

Fluctuating nature of loss may be missed by screening, especially summer screening

Hear Glue Ear mobile app can be used by families to estimate fluctuating hearing levels

Glue ear - consequences

Reduced exposure to acoustic-phonetic stimuli impairs knowledge about syntactic structure leading to long term SL and social impairments

Some use quiet voice (perception via bone conduction)

Risk of dysfluency - physical illness puts system under stress

Poor perception/production of high frequency low intensity consonants impacts phonology, morphology, comprehension and literacy

Behaviour

No consequences if other factors are positive (i.e. SES class, family history, no additional difficulties)

Difficulties listening in noise affects children with MML and unilateral losses

Listening in noise is a skill that develops during childhood

Dividing attention between teacher and other students increases listening effort

Greater listening effort has consequences:

Cognitive overload - fewer cognitive resources left to understand and remember content

Can lead to deficits in academic performance

Listening fatigue

Medical interventions for OME

Information and watchful waiting - NB 60% of parents need more support to minimise speech & language delays

Medication: antibiotics

Surgery: grommets, adenoidectomy

Dietary advice: avoidance of mucus producing products

Autoinflation
Hearing aids (after 3 x grommets)

SLT/TOD management of MMHL and unilateral deafness

Monitor hearing & speech/language development

Advise on listening environment, increasing signal to noise ratio, use of hearing tactics (face-to-face communication)

Difficulties with sound localisation and background noise

Language groups for children

Language advice and support for parents, e.g. Hanen

Speech intervention

Children may have difficulties with high frequency, less visible sounds (e.g. stopping of fricatives, fronting of velars)

When working on speech, consider:

What can the child hear? Check auditory discrimination

Use of visual/tactile/kinaesthetic input to support discrimination and production

Teaching a skill may not be enough, important to support generalisation

Impact of postlingual deafness

In the absence of cognitive impairment:

Language unlikely to be affected, except for learning new vocabulary

Speech and voice may deteriorate due to differential reliance on auditory feedback of speech

Consequences (and therefore management) will differ depending on progress of deafness

Psychosocial consequences:

Social isolation

Mental health issues

Employment difficulties, e.g. interviews, in the workplace

Intervention with postlingually deaf adults

Is a hearing therapist available/involved?

Check audiologist/hearing therapist advice on use of amplification & assistive devices

Check vision

Advise significant others, work colleagues, etc., on deaf awareness and hearing tactics to support receptive language

Contact voluntary organisations and support groups

Refer for psychological support

Communicating with deaf clients

hearing aid

quiet environment

don’t shout but do speak up

3-6 feet distance

check H/A is working

lipreading

3-6 ft distance

light on your faceclient has back to the light

don’t obscure your face

are your lips readable

don’t over exaggerate speech

speak slowly and clearly

allow processinf time

avoid distracting jewellery/clothing

rephrasekeep arms stilluse visual cues- gesture/facial expindicate change of topic

ensure understanding

write down if necessary

SIRS: Speech Intelligibility Rating Scales

5 Connected speech is intelligible to all listeners; easily understood in everyday contexts.

4 Connected speech is intelligible to a listener who has little experience of a deaf person’s speech. The listener does not need to concentrate unduly.

3 Connected speech is intelligible to a listener who concentrates & lip-reads within a known context.

2 Connected speech is unintelligible. Speech is intelligible within single words when context & lip-reading cues are available.

1 Pre-recognisable words in spoken language. Primary mode of everyday communication may be manual.

What makes a good speechreader?

Speechreading correlated with motion detection abilities in adults

Target speech perception/ comprehension skills by making the most of visual cues:

Face to face communication

Clear speech patterns

Good lighting

Shadowing task:

Tester reads a passage sentence by sentence

Client repeats exactly what they hear

Provides information on how much language client accesses, e.g. analyse no. of words repeated, errors in sounds perceived

Try with/without speechreading

Check comprehension with/without visual cues, e.g. TROG:

With/without speechreading

Auditory comprehension vs reading

Discourse communication strategies

and conversational repair - clients may:

Monopolise conversations

Not admit they don’t understand