The earlier an infant/child is provided earlier intervention services the better their outcome in all circumstances but especially for children with hearing loss. Outcome viabilities range from being representative of peers of similar ages to being severely behind their same age peers. This range is common with children who have hearing loss, with or without implantation, but when provided services earlier rather than later, outcomes are more likely to be positive (Jackson & Schatschneider, 2014, p. 539-540).
Furthermore, the earlier an infant/child gets amplification or implantation, the better their outcomes (minimizing their delays), likely due to their better language skills and more interactions including collaborative play (Zelenik, Kominek, 2012). Sometimes, children who are implanted have less impressive outcomes but often times these are the same children who have more severe hearing loss. These same children have to wait until at least 12 months old to get implanted, leaving them without as much opportunity to perceive their surroundings (Jackson & Schatschneider, 2014, p. 52). Sometimes children with unilateral aural atresia do not have as positive outcomes, which may be due to a wait time regarding interventions and sometimes children with unilateral aural atresia do not use their devices with the same consistency or for as long of a time as bilateral aural atresia (as cited by Attaway, Stone, Sendor & Rosario, 2015, p. 355).
This is often related to compliance of use, which is an extremely important component to consider with these young children. The earlier children are fitted, the more compliant” they are likely to be (Attaway, Stone, Sendor & Rosario, 2015, p. 355). As clinicians, it’s important to be aware of noise in an environment when working with children with TCS who have hearing loss. Most children with hearing loss need quieter environments to better consume speech and language and to understand speech and language. This is extremely significant to recognize because often times children are spending their days in very noisy environments, often classrooms (Nittrouer, Caldwell-Tarr, Tarr, Lowenstein, Rice & Moberly, 2013, 513-524).
This lack of access (and possible lack of access to early intervention) is important to recognize because the more vocabulary a child has and the more phonological awareness a child has, the more likely they are to make better predictions about what might be being said to them. Therefore, not only should clinicians be aware of noise and provide supports for environments such as that, but they should also make sure to build language skills like vocabulary knowledge and phonological awareness (which can be done through direct instruction, experience, and use of amplification or implantation.
This like many other components are cyclical. The more a child is exposed to quality interactions, the more likely they are to pick up vocabulary and grow in phonological awareness. The more vocabulary and phonological awareness the child has, the more likely they are to engage with others (Nittrouer, Caldwell-Tarr, Tarr, Lowenstein, Rice & Moberly, 2013, 513-524). Moreover, early identification helps to allow professionals provide information to parents regarding intervention plans, surgical intervention, and amplification options (Zelenik, Kominek, 2012).
Children with hearing loss often have phonological awareness issues, which affect literacy and reading skills, despite intervention. Therefore, phonological awareness is extremely important component of intervention to include with all children with TCS who have hearing loss (Ching, 2015, p. 347). Often, these children are impacted from the very start of their life within the womb, because they cannot hear sounds neonatally (language, familiar voices, calming music, etc. ), as well as with the few months of life.
Repetitive shared book reading with intensive direct instruction is one way to assist these children in learning language, as it positively affects vocabulary development. (as cited by Bobzien, Richels, Shwartz, Raver, Hester & Morin, 2015, p. 263). Vocabulary development positively affects reading fluency, comprehension, literacy, and print awareness. Shared book reading utilizes specific tools that assist with direct instruction including expansion, elaborations, questioning (specifically cloze questioning and individual/choral responding).
Expansions include extending and adding on to a child’s utterances within which a target utterance is used. Elaborations require facilitator to present definition of target word/s and its function within the context of the book. Questioning requires the facilitator to question a child about pronunciation of target word/s, as well as regarding comprehension of target words. Cloze questioning utilizes a fill in the blank technique and individual/choral poses a question within which the target word/s apply and the individual child or a class as a whole has to answer (as cited by Bobzien, Richels, Shwartz, Raver, Hester & Morin, 2015, p. 63).
Although there still needs to be more research done regarding use of this technique with children who have hearing loss specifically, there is a large enough amount of research stating its efficiency with typically developing children learning language (Bobzien, Richels, Shwartz, Raver, Hester & Morin, 2015, p. 263). DesJardin, Doll, Stika, Eisenberg, Johnson, Ganguly, Colson & Henning also pontificate the value in joint book reading with children who have hearing loss through dialogic reading on a daily basis (2014, p. 167).
They identify facilitative language techniques as lower and higher level. The lower level techniques include linguistic mapping, comments, imitation, label, directives, and closed ended questions. The higher level techniques include parallel talk, open-ended questions, expansions, and recasts (DesJardin, Doll, Stika, Eisenberg, Johnson, Ganguly, Colson & Henning, 2014, p. 168). Often times, parents of children with hearing loss are most comfortable utilizing lower level techniques but need more assistance in feeling comfortable utilizing higher level techniques.
Guiding parents to utilize the correct techniques, dependent on the child’s language level is another extremely important component in the process. Linguistic mapping is the conversation partner’s speech interpretation of a child’s distorted word or utterance. Comments include statements or phrases that a conversation partner provides as confirmation of recieval of a message or to continue a conversation. Imitation is when a conversational partner repeats a child’s message precisely. Labeling is when a conversation partner provides vocabulary that corresponds to a referent within the book.
Directives are messages provided by the conversational partner that are meant to elicit specific responses or actions. Closed-ended questions are questions provided by the conversation partner to the child that are meant to elicit only a one-word response. When the conversational partner narrates whatever the child is doing, looking at, or referencing. Open-ended questions are questions that elicit answers that require more than one word answers. When a conversational partner expands upon a child’s utterance/comment by making it more complete with more complicated and correct syntactic structures.
Recast messages are messages that are reformatted into questions by the conversational partner. These are all important for clinicians to utilize as deemed appropriate when directly coaching parents and/or modeling for parents. Coaching may include demonstrations, videos, or one on one instruction, while utilizing specific verbal feedback throughout the process. The specific verbal feedback helps parents to learn the strategies and feel good about themselves during the process (DesJardin, Doll, Stika, Eisenberg, Johnson, Ganguly, Colson & Henning, 2014, p. 177).
Findings revealed that parents’ perceptions of shared book reading behaviors at 8 months of age were positively linked to later expressive language skills at 12 and 16 months of age” in children with normal hearing (as cited by DesJardin, Doll, Stika, Eisenberg, Johnson, Ganguly, Colson & Henning, 2014, p. 168). This is extremely important to keep in mind as SLP/professionals, who work with parents, providing them as many positive experiences and creating a mindset that supports competence and confidence, because in turn children will be positively affected.