demonstrates how the hearing development of children in these very young ages can be supported, how we need to talk to them in order to foster a natural acquisition of speech and which is the role of co-working pedagogic professionals in this process.
- 1 Introduction
- 2 Chapter 1-Linguistic communication with the child with hearing impairment in group situations – how can we best understand each other?
- 3 Chapter 2-How can I support the child in their hearing development?
- 4 Chapter 3-Early intervention for children with hearing impairment – a specialist field facing new challenges
- 5 References
The parents of normal hearing children do not “teach” them language. Rather, they unconsciously create an environment in which they can actively acquire listening, linguistic understanding and speech skills. This takes place entirely in everyday interaction – while changing nappies, feeding, playing, looking at picture-books, tidying up, laying the table, in the playground, and during other similar activities. Commenting on this, Morag Clark from the UK says: A deaf child has special needs, but these are not for something different, but for more of normality. Never before have children with hearing impairment (even if they are profoundly deaf) been able to acquire diversified language skills as they are today. An important prerequisite for this is that the identification is as early as possible, with effective medical, technical and language support provided. As, even for children with hearing impairment, hearing and language are acquired in everyday interaction and relationships, it is not only the parents that have an influence on the child’s development, but all other caregivers as well. In this way, you too can support the child with hearing impairment in their listening and speech development. In all areas of development there will be phases where great headway is made, phases of more modest progress and phases of apparent plateauing – and listening and language development are no exception here. The golden rule is: keep sharing information with the parents and specialist caregivers. Regular two-way discussion about the child is the best foundation for getting to know and understanding them even better and, even in group situations, for ensuring they have the best conditions for development. It is quite normal if you are occasionally uncertain about how to relate to the child and how to use the technology. Talk about this openly – you will be showing that you are taking a responsible attitude towards your role and wish to expand your expertise.
All children with hearing impairment are different and grow up in their own individual social environment. Nevertheless, there are still a number of basic rules that are helpful for interaction. This module gives a clear, hands-on description of how you can optimize communication with the child with hearing impairment in your group and thus also foster their listening and language development in dialogue, drawing on the things of everyday life.
Chapter 1-Linguistic communication with the child with hearing impairment in group situations – how can we best understand each other?
In this chapter you will find out, with the aid of many clear examples, how communication with the child with hearing impairment can take place successfully. How should I talk to the child, what should I talk about, and how can I encourage the child himself to speak? As this course is designed for those working with children aged 0-3 years, it contains suggestions for communicating with children with hearing impairment who are in the initial phase of hearing and language acquisition.
How should I speak to the child with hearing impairment?
In group situations, make contact with the child using eye contact and/or by addressing them by name when you want to speak to them. In this way, the child knows ‘you mean them’ and so can focus their listening on you. If you try to get their attention by suddenly touching them, you may startle them if they have not seen you approaching. They also need to learn how to speak to other children if they want something from them, instead of just tapping them on the arm or shoulder.
Speak at normal volume – not too quietly and not too loudly. Amplifying the sound is not your job but that of the hearing aid or cochlear implant. And remember that speaking to the child more loudly will distort your facial expression and pronunciation.
Don’t speak too fast or too slowly. If you slow down your speech, you change its intonation, stress and rhythm. These aspects of speech are known as ‘prosody’. For normal-hearing and children with hearing impairment alike, prosody can be laden with meaning, helping to make clear (for example) that you are giving praise, making a factual comment, confirming something or perhaps expressing impatience. Natural prosody is, therefore, very important. What’s more, it means we are giving the child a natural speech model and thus helping them to speak in a natural way themselves.
Speak clearly, but avoid exaggerated movements of the mouth. These make lip-reading harder as the movements are distorted, and also affect the natural intonation of speech.
Speak in a lively way, i.e. melodiously and stressing the important words. This involves contrasts of volume, as in, “Hey, great, you can already do that all by yourself!” or by elongating vowel sounds, as when playing ‘peekaboo’ hiding games with a 12-month-old child: “Wheeere’s Ben? Theeeeere he is!”
Repeat the most important ‘carriers of meaning’, as you naturally do with all younger children, as in, “Look, Anna wants a go on the swings, too. Will you let her have a go on the swings?” These repetitions are very important in the initial phase of language acquisition, as a child with hearing impairment needs to hear words more often if they are to learn to understand their meaning. If, however, the child has already achieved a good level of linguistic understanding, so that they do not really need these repetitions, you need to make sure you use them less often. The child should, as a rule, learn to respond and to understand what is said when spoken to only once. If, however, they are used to having everything said several times, they will tend to listen to spoken language less and less attentively.
Children with hearing impairment often have to piece together the message from individual bits they have understood. So, for important utterances, mix and match a choice of different words to get the main point across. For example, it is harder to understand if you just say, “Max, come along,” than if you say “Max, come along. We’re going outside into the garden. We wanted to collected chestnuts, remember?” With the second example, Max can glean from several different words what is about to happen. If he has not heard (or understood) the word ‘outside’, he can still piece together the message from the words ‘garden’ and ‘chestnuts’.
Use lively facial expression and gesticulation. If your body language is natural, this makes communication natural and lively, and reinforces the message of your words.
Speak in your own dialect, if this is the one spoken locally. Only an unfamiliar dialect that is not otherwise spoken within the group would confuse a child with hearing impairment.
What should I talk about with the child with hearing impairment?
Let the child set the agenda. When they are a baby, this might take the form of happy kicking; when they are older, they might point to some object and later they use language, as in the questions of a child using their first two-word phrases: “Bear ouch?” But keep asking yourself: are you really talking about the same thing? It might be that you are focusing on the same object yet talking at cross-purposes. If a child is watching the marbles in a marble run, fascinated that they roll so fast all by themselves, and then suddenly drop into the next level, and you say, “Look, here comes the red marble – see, this one’s red!” then, while you may be playing with the same object, you are focusing on different things: you are talking about the colour of the marbles, whereas what interests the child is how fast they move. You can, of course, try to arouse the child’s enthusiasm for something else or for another aspect of the game, but if they don’t respond, you should switch back to the child’s own agenda.
Don’t tell the child what the objects are called: talk to the child about them. Not: “Look, these are Wellington boots. These shoes are called Wellington boots”, but, “Oh dear, your Wellington boots are really dirty,” or “Have you got new Wellington boots? They’re a lovely blue colour, aren’t they!” What objects, animals and people are like is far more interesting than what they are called. The exciting things about a tiger, for example, are that it has sharp teeth, bites and can run very fast. Interesting things about a cup might be that it is hot, it can break if it falls, it is dirty and has to go in the dishwasher, or that there is a picture of the child’s much-loved Pooh Bear on it.
Repeat what the child says. It’s not how the child says something that is important, but what they mean. Show that you have understood the child by repeating what they say. Child: “Look, boken!” Adult: “Your pencil’s broken? Oh yes, the lead’s broken off. Come on, let’s get a pencil sharpener.” In this way, the child will feel understood and they hear the correct pronunciation, grammar and vocabulary without being directly corrected and getting the feeling that they have done something wrong.
Make sure you don’t over-simplify your language. If you aren’t always a little ahead of the child in language level, they can’t progress. For example, they cannot learn ‘Wellington boots’ if you only ever say ‘shoes’, or learn ‘switch off’ if you always say ‘turn off’.
It is important that you speak a lot with the child with hearing impairment. However, always be aware of how receptive the child is at any given moment. For example, is the child tired, over-stimulated or absorbed in an activity right now? Even children only a few weeks old clearly show whether they are in the mood to communicate or not. There is no point in overwhelming the child with language. This will only make them less willing and able to concentrate on listening, not more. Listening – and even speaking – must be interesting and worthwhile for the child.
How can I encourage the child to speak; to actively use language?
Elicit spoken language from the child, but don’t demand it! Guidelines such as “You can give the child what they want only when they try to name the object” are not helpful. If a child merely points and makes babbling/non-speech sounds, this shows it is still very difficult for them to express themselves more precisely using language. Speaking, communicating and being understood are fundamental needs for every human being. If a child is able to do so, they will apply their linguistic skills. Insisting on a response, however, generally leads to the child withdrawing into themselves or to a power struggle between the two interacting parties. For example, a child may be unable to carry out the request “Say: ‘An ice-cream, please!’”, and therefore they do not get what they want and start crying. One can easily imagine how the situation would escalate from there.
You can, however, elicit language from the child without actually insisting on it by using easy methods in day-to-day interaction:
Wait a moment, and take a break from speaking, so that the child has time to muster their thoughts and say something themselves. In a natural dialogue, the speaker and listener take turns. If you insert pauses, this sends a signal to the child that they can now assume the role of the speaker. You can, for example, after turning over the page in a picture-book, first wait and see if the child points to something on the new page or comments on it using spoken language.
Natural opportunities/reasons for using language often arise when something does not happen as expected. An example: try, from time to time, briefly delaying an action that the child expects. If something does not happen in the way the child anticipated, they will make eye contact with a questioning look and perhaps say something. If, for example, you are rolling a ball back and forth to each other and briefly hold onto the ball, the child will take notice and may say “My ball!” If everything happens as expected, it is not usually necessary to say anything – natural opportunities and reasons for using language do not arise. If, however, the predicted action does not materialize, or a person or an object is not there and needs to be looked for, or something is broken, or if the child needs help, or if they cannot reach something they want, then communication really is necessary. For example, a child cannot be expected to name their drinking bottle without a good reason. However, if the bottle is packed away and the child looks around for it, this provides a natural reason and opportunity for using language, and the child may say “Bottle?”
A child’s first words are often associated with strong emotions: maybe Mummy has disappeared from view, making the child anxious so that they call out “Mummy!” Or a toy car has rolled under the sofa and the child cannot retrieve it unaided, gets annoyed and calls for Grandma’s help: “Grandma car!” Or a box or a bag is – against expectations – empty and, on opening it, the surprised child exclaims, “Empty” or “Gone!” Or a child is playing with the light switch, enjoys making the light come on or go out and comments enthusiastically, “Off!” Or a teddy bear is provided with a sticking plaster and the child declares with a serious expression, “Teddy ouch!” The child is solemnly warned that the candle’s flame is hot and, impressed, repeats “Hot!”
Ask questions, for example, when looking at a picture-book: “Who’s that hiding there?” or “I wonder what the tiger’s going to do next; what do you think?” But avoid asking the children obvious test questions like “What’s he called?” or “What’s he doing?” Children are able to notice from a very early stage whether they are being asked real questions or whether the other person is just testing to see if the child can produce the hoped-for answer.
Ask ‘alternative questions’. If, for example, the child points to the table and says “Ah!” or “Drink”, you can ask: “What would you like to drink? Tea or juice?” Even if you already know what the child usually wants, this is a good opportunity to model the right words to the child (‘drink, tea, juice…’). In this way, the child hears the words and will soon be able to use them themselves. Even if the child does not yet specifically answer, or they point again and respond only with “Yes,” it is still worthwhile, by means of an alternative question, providing a model for a possible reply. This model serves as an aid in the initial phase of speech acquisition, but as it predefines (and thus restricts) the content of the answer, it is important to later scale back the use of these alternative questions, too.
If the child is further on in their development, then ask open questions: “What would you like to drink?” After a visit to the zoo, the question, “What animals did you see?” is far more restricting than the question, “Which animal did you like best?” The first question is more likely to result in a list, and the second in a conversation, with a real information gap – the child is telling me something I genuinely don’t know and which interests me.
Comment on your own actions and those of the child. If, for example, you are playing together in the sandpit, say, “That’s a deep hole you’re digging. That’s going to take an awful lot of digging, isn’t it! I’ll just go and borrow Lisa’s bucket and spade, shall I?” If the child in the picture-book points to a child jumping in a puddle, say: “She’s having fun! Splish, splosh! I think this girl’s trousers are getting really wet. Do you like jumping in puddles?” In this way, the child will hear the right words and phrases for this context and will be encouraged to make their own utterances.
When playing and looking at picture-books or telling stories, use direct spoken language. If you use different voices for the different characters, you are providing new listening experiences. The mouse might speak quickly in a high-pitched voice, and the bear in a slow, deep voice. These touches bring games and picture-book sessions to life and encourage the child to spontaneously imitate you. The mouse in the story might say to its 14 mouse children, “Night night, sleep tight!” or the bear might warn another animal and say “Watch out!” Animal noises like “Moo” or “Woof” are direct spoken language too and encourage imitation. However, don’t overdo these animal sounds.
Songs, verses, finger games and singing games are a good way of developing language skills, containing as they do natural repetition. Young children love repeating what they know. Their vocabulary is expanded, and their feeling for language fostered, by rhymes and the like; among the many benefits, their memory for language, melodies and sequences of movements is stimulated. Verses and songs with a ‘fun finish’ are especially popular with babies and small children. They wait very eagerly and attentively for the ending, listening very carefully right until this part comes: “Shake the blanket, shake the blanket, shake the blanket … over!”
If the child does not yet say much, you can elicit spoken language by letting them finish a verse, a line of a song or a sentence: “Jack and Jill went up the…” “hill!” “Humpty Dumpty sat on a … wall!” “Tell Daddy who we saw in the garden today.” “A tiny little…” “Kitten!” “What do we need to lay the table? Spoons, plates and…” “Cups”!
Linguistic awareness is enhanced by hands-on experience. Children with hearing impairment do not learn the meaning of words from picture cards. Active (spoken) vocabulary does not develop at first through images either, but in actual everyday and play situations. Children learn by continuously having new experiences in day-to-day life and play, by physically connecting with things in their world – taking hold of, holding onto and feeling things, seeing, climbing, running, hopping etc. – and through the language they hear while doing so. Give the child plenty of opportunities for movement and to actively experience the world around them. A book about a building site is no substitute for the multi-sensory experiences a child can enjoy if together you go and watch all the goings-on where a real house is being built, or if the child plays ‘building sites’ with other children in the sandpit. Books are, initially, a valuable addition to actually experienced situations; later, children will, of course, also learn about new concepts from books.
Even if the child is progressing well in their hearing and their spoken language development, it must not be forgotten that hearing and listening – and thus everyday life in general, throughout the day – ‘take more out of’ these children than their normal-hearing peers. You will, therefore, find that the child often does not respond when spoken to. Be patient, wait a moment and then, simply repeat – but not in a reproachful way – what you’ve said. If the child still does not react, try to rephrase what you want to say. You might, for example, say: “Kim, would you like to help me lay the table?” If the child still does not respond after you have repeated this, you might say: “Do you want to fetch the plates and spoons and bring them to the table?” Don’t tell the child off if they do not listen or respond. Hearing needs to be something positive and rewarding for the child. There will always be days or phases where they are more – or less – switched on to listening, and there may be many reasons why a child with hearing impairment sometimes does not respond (although, of course, it’s necessary to check that the hearing aids or cochlear implants are working properly): They might be absorbed in an activity, or tired, or distracted, or do not yet understand the meaning of the words you are using, or it might be noisy there, or the child just doesn’t feel like listening – like any normal-hearing child at times. Moreover, children fitted with hearing aids often do not hear as well when they have a cold, as their inner-ear hearing disorder is maybe compounded by a middle-ear problem (i.e. conduction hearing loss).
If you fully commit yourself to the child with hearing impairment; if you give yourself and the child time to get to know each other and try to get talking with them, even though they are only just setting out on the journey of hearing and spoken language development, then you will find that interaction can prove successful – even with this child.
A child with hearing impairment can understand me better if I:
a) speak louder;
b) speak with pronounced mouth movements;
c) speak using very emphatic prosody;
d) keep my utterances as short as possible.
To help the child acquire speech understanding, it is important that you:
a) make greater-than-normal use of nouns (only introducing other types of word later), because the child is especially interested in what objects, people and animals are called;
b) repeat and extend what the child says;
c) provide the child with lots of picture cards so that they can associate words with their meaning;
d) always speak with the child a lot, even if it sometimes seems that they are not listening.
A child with hearing impairment can be encouraged to develope spoken language if:
a) you ask ‘alternative questions’ at the start of the active language-development phase;
b) you test them, using picture-books or word cards, on the words they can already say, by asking, “What’s that?” or “What’s that called?”, and thereby reinforcing these items;
c) you do not respond to the child’s gestures and babbling/non-speech sounds, and ask the child to say what they want;
d) you model the words to the child and request them to speak: “Say car!”
If a child with hearing impairment does not respond immediately when spoken to:
a) I leave it for now and try again later;
b) I say: “(Child’s name), look at me!” and repeat what I want to say a good deal louder;
c) first I wait for a bit and then repeat what I want to say, maybe putting it a different way;
d) I repeat the same sentence several times.
Chapter 2-How can I support the child in their hearing development?
In the first part of this chapter you will learn how to help the child get used to their hearing aids or cochlear implants and how you should respond if, for example, the child removes their equipment from time to time. The main body of this chapter outlines how you can support the child in their hearing development. This involves exploring questions such as: what is the value of noise-generating toys and musical instruments as opposed to everyday sounds?
How best can a child get used to their hearing aids or cochlear implants?
A vital basis for good hearing development is that the child wears the right hearing aids or cochlear implants – which are in good working order – all day. These are a pre-requisite for auditory language acquisition in everyday life (see also module 3).
Following the initial fitting of hearing aids or cochlear implants, the expectations placed on these devices are usually very high. Everyone is hoping to see the very first – or improved – hearing responses and that the child will get on well with the new equipment. Most children accept them straight away and are happy to wear them for many hours a day right from the start, whereas others require a couple of weeks – or even two to three months – before they end up using the devices continuously. Children who do not adequately benefit from hearing aids, because they have insufficient residual hearing, sometimes do not accept them at all. These children then (following this trial period with hearing aids) tend to receive cochlear implants. A basic rule is: if a child does not like wearing their hearing aids or implants, or suddenly removes them, you first need to establish whether there are underlying technical reasons or medical causes for this, such as: are the batteries flat? Are the devices set at too loud or quiet a level? Are they defective? Is the child sensitive to the earmould material? The acoustician or other professionals can find out, whether there are reasons like that for problems in accepting the technical devices.
Some children find it more pleasant if, immediately after a ‘break in listening’ (i.e. at night-time, or a midday nap), a quieter programme is provided first, resuming with the normal setting only after 15-30 minutes. The parents will discuss this with you.
Infants like investigating these funny new things that can be pulled out of their ears, looked at and put in their mouths. The soft earmoulds make good chew toys, too! Even babies soon realize that they immediately get adult attention if the devices are found whistling away in their hands or end up on the carpet. Somewhat older children, too, such as those who get their first hearing aids at the age of 20 months, very soon understand this link between their own behaviour and adults’ responses. Often all it takes is for them to move their hand towards their ear and someone will come and give them attention. Always make sure that, with infants and toddlers, the devices are attached to the clothing using a corded child-safety device. This will enable you to remain unfazed when you see that the devices are no longer in the child’s ear where they belong: they will be hanging safely on the child’s clothing where they cannot be damaged – because they will not end up in the sandpit or on the tile floor – and cannot get lost. If, rather than coming and reinserting the devices immediately, you wait a few minutes, the child will no longer register the connection: “If I pull out my hearing aids, someone then comes and gives me attention.” With some children, however, a consistent policy of immediate reinsertion may have the desired effect. Show the child the device before putting it back in, so that they know what is about to happen. So that you definitely know which device belongs in which ear, it is a good idea to have them in different colours or put stickers on them to tell the left and right one apart.
How does the child become familiar with sounds and learn to relate them to their sources?
In our everyday lives we hear speech, sounds and music. The most important ‘instrument’ for learning to hear is the voice of Mum, Dad, other family members and close caregivers such as the childminder, crèche supervisor or nursery school teacher. Always remember that ‘hearing must be meaningful’. So make sure that the child has a reason to listen: for example, that something happens when you call the child’s name. When children begin to respond to their name, this will encourage them to keep trying this out. If, however, this does not result in anything happening, the child will soon stop looking around to locate the speaker when they hear their name.
As well as language, of course, children need to become familiar with sounds and their origins. However, it makes little sense to start helping the child learn to listen by providing them mainly with musical instruments or noise-generating toys. Writing on this, Horsch (2007) says: “The practice, which can be observed on many video recordings, of offering the child one noise-generating toy after another is not really capable of capturing their attention; the hearing sensation is often merely a stimulus to which the child briefly responds but which does not really interest them. It does not lead to any real communication between mother and child, and it sometimes all seems a bit hectic, because switching between different playthings often leads to the nature of the interaction being changed too. The situation has been wasted, the moment has gone, and the opportunity to learn to ‘hear meaningfully’ is squandered.” It makes far more sense to draw the child’s attention to everyday sounds and to explore them together, such as a running tap, the vacuum cleaner, the doorbell, footsteps on a gravel path, etc. You might also use a ‘listening gesture’ such as putting your finger to your ear and saying “Listen!” Noises provide us with important information in everyday life. Children learn these messages best when they create the sounds themselves. Try watering the plants together and filling a small watering can. The child will listen intently how it sounds when they turn on the tap and how the noise changes as the can gets fuller. This provides a wealth of experiences and the child hears the commentary that goes with them, such as: The watering can starts off light and empty, then gets full and heavy; you have to carry it carefully, walk slowly, some water has slopped out; the flowerpot is up on the windowsill; the soil is really dry, you shouldn’t pour too much water in … and the child is praised for how well they can manage this alone!
Draw the child’s attention to the sound of a ring or knock at the door: “Ding dong, that’s the doorbell, I wonder who that is? Come on, let’s take a look.” When you then take the child with you to the door, they will learn that (in response to this sound) the door is now opened and someone is standing in front of it because, say, a child is coming to visit or a parcel is being delivered. You could even try playing an ‘Open the door – close the door’ game. One adult rings or knocks, another adult opens the door with the child, and then the roles are reversed.
If an eight-month-old child is playing with a spoon, which they bang on the table or on other pieces of cutlery, they will learn how the clatter of cutlery sounds. When they are somewhat older and able to help lay the table or do the dishes they will, in the process, become familiar with typical kitchen noises. If they hear these sounds later, even when they are playing in the next room, they can ‘place’ them and will not be bothered by them.
Together, shake packages and game boxes to hear what’s inside. This is a far better place to start than, say, ‘noise-generating cans’ (which are filled in an artificial way with different material like rice or small stones).
When tidying up together, put the bricks in the brick box, the wooden rails in the train box, and the toy cars in the car box. One of the things the child will learn by doing this is that Lego bricks make a different noise than wooden bricks do, and that the wooden rails sound different when they fall into an empty box as opposed to one that is half-full. And, by the way, if you talk while you work, all clearing-up sessions offer good, built-in practice for generic terms (cars, sand toys, cutlery…), with lots of scope for repetition of language: “There’s another piece of track, please fetch the piece of track from under the bookshelf.” And another tip for reducing noise levels in the nursery: line the toy boxes with carpet offcuts so that filling them up won’t make so much noise. (see also module 2 and 10 to improve the acoustic conditions in the group)
Outside, too, the child will encounter noises – when they throw stones down the slide, when they jump into a pile of leaves in autumn, when they use the bell on their tricycle, when cars drive past, and so forth.
One more tip to finish off with: in a room in which a lot of people are talking across each other with a confusion of noise – during free-play time, for example – it is much harder to pick out the teacher’s voice than a noise. So use a ‘change signal’ such as a bell, chime bar or something similar. The child with hearing impairment, too, will find it far easier to make out this sound above the babble of voices, will switch into ‘attentive mode’ and then listen to what the teacher is saying.
The examples given here clearly show how diverse and intense hearing and language experiences can be in many, quite everyday situations, and using perfectly normal toys. This is especially true of the early stages when the child is first exploring the world of sounds around them. So there is no need to buy special noise-generating toys that produce artificial animal sounds and the like at the touch of a button. A spoken ‘moo’ when reading a picture-book or playing with toy animals is far more valuable. It is, of course, also enriching for the child if you provide experiences with songs, verses, rhythms and simple musical instruments.
If a child keeps removing their hearing aids:
a) I always turn to the child with a friendly smile, take them on my lap and put the hearing aids back in straight away;
b) the first priority is always to find out if there is an underlying technical or medical problem;
c) I switch to a lower volume setting or select a quieter programme;
d) I get cross with the child.
The following are, at the start, especially important for hearing development in babies and toddlers:
a) The voices of their caregivers in dialogue and everyday sounds;
b) Noise-generating toys with buttons, because the child can use them to ‘trigger’ sounds themselves;
c) Speaking to the child loudly and clearly;
d) Loud noises such as drumming, since the child can easily hear these.
Toddlers with hearing impairment learn the origin (and thus the meaning) of sounds best:
a) by using a CD of noises and matching picture cards;
b) when different sounds are created for the child’s benefit;
c) when the child’s attention is especially drawn to loud noises;
d) when the child can create sounds itself and explore them.
Chapter 3-Early intervention for children with hearing impairment – a specialist field facing new challenges
You are, hopefully, bound to be assisted in your work by a professional who specializes in working with infants and toddlers with hearing impairment.
In this chapter you will learn about key aspects that now make the specialist field of early intervention for children with hearing impairment challenging in new and different ways. The term ‘early intervention’ primarily includes the guidance and ongoing support of families with their children with hearing impairment as well as work with these children in special groups for the hearing impaired from babyhood right up until they start school. A further area that is increasingly growing in importance – and one which this book has particularly in mind – is advising and assisting other caregivers who look after the children on an integrative basis, e.g. as childminders or crèche supervisors. (see also module 4 and 10)
The children are getting progressively younger
For the sake of the child’s overall development, it is crucial that hearing impairment is diagnosed as early as possible. Changes and advances over the last 15 years mean that we are now well on the way towards universal hearing screening for newborns. As a result, the age of the children with whom education professionals and therapists are working is becoming progressively lower. Specifically, this means that children, who are hard of hearing or profoundly deaf, are diagnosed immediately after birth and receive their first hearing aids at around eight weeks, which thus marks the onset of early intervention.
It is therefore becoming increasingly necessary for professionals to acquire detailed knowledge in many areas: early-childhood communicational development, building the parent-child relationship, hearing and speech development, the role of play, and the child’s overall development.
Even in our work with infants under one year of age, individual children and their families are very different and must receive tailor-made help that takes account of these differences.
The diagnosis may come in many different ways:
A diagnosis by means of neonatal hearing screening takes the parents completely by surprise
There is already a child with hearing impairment in the family and the newborn child is also hard of hearing or profoundly deaf;
The father, mother or both parents are hearing-impaired and their baby has the same diagnosis;
The diagnosis comes in the wake of an illness (such as meningitis) in the first year of life;
The diagnosis comes after the child has been given ototoxic drugs (i.e. medication that damages the hearing);
Premature children weighing under 1,500 grams have an increased risk of hearing impairment;
Children with other difficulties may, for example, have hearing impairment as part of an overall syndrome;
Children with ear malformations that are evident immediately on birth;
Children whose parents suspect hearing impairment and have their suspicions confirmed during the child’s first year.
Within these individual categories, too, we see a very wide range of different situations. If, for example, a sibling child is hearing impaired, many normal-hearing parents (note: 90 % of all parents of children with hearing impairment have normal hearing) find it incomprehensible that fate has dealt them another cruel blow – the birth of another child with hearing impairement -, whereas others may have prepared themselves for the possibility that a further child could be affected. Hard of hearing or deaf parents, too, take the news in very different ways. This depends not least on how well they themselves manage to integrate their own hearing impairment into their everyday lives. Parents of children with auricular (outer ear) malformations and hearing impairment are confronted with the problem immediately after birth and often face months of anxiety as to whether the child might not also have other malformed organs or developmental problems. There are families who have a stable social network, and there are also mothers or fathers who have to cope with the diagnosis – and get on with their daily lives – more or less alone. Many more examples could be given.
However heterogeneous a group of early-intervention children and their families may be, and however differently families deal with the diagnosis of hearing impairment, the initial period with a new baby is a time of tremendous upheaval in any family. The work of an early-years practitioner often involves an outsider coming into the home during a highly sensitive phase, where nothing is as it used to be. The family are still feeling their way with the new arrival, learning to integrate them into their lives and adjust into new daily routines. It is an emotionally charged time for everyone anyway, and then, to cap it all, comes the diagnosis of hearing impairment: “The parents are in a state of emotional turmoil, facing feelings of guilt and a sense of duty, anxiety and grieving, uncertainty and happiness” (Pöllmacher/ Holthaus 2005). Work with infants with hearing impairment thus requires more than specialist knowledge of child development in the first year of life: these professionals also need to provide highly skilled guidance and an empathetic understanding of each family’s individual situation.
New products and techniques are coming on the market at an ever-increasing rate to cover a wide range of needs: auditory diagnostics, hearing aids, cochlear implants, additional equipment (such as FM systems) and apparatus for checking and adjusting these assistive hearing devices. Although the early-intervention specialist does not have to know every technical detail, she needs to keep on top of developments in the technology so that she is, say, able to reflect together with the parents on the input they have received in consultations with doctors, hearing-aid acousticians or at the cochlear implant centre. She must also be able to check that the devices are working properly and advise parents or other caregivers on daily checks and maintenance. (see also module 3)
The changing role of the early-intervention specialist in parental guidance and support
The potential to achieve high level outcomes for children with hearing loss has increased tremendously in recent years due to diagnostic and technological changes. Early intervention programmes for children and their families, which are the key to achieving long-term high quality outcomes, have to embrace this change. The models employed in intervention programmes are a critical factor and it is now a big challenge for professionals to address their role in working with families. Morag Clark describes this challenge in her recently published book on the Natural Auditory Oral Approach: “Observation of programmes around the world shows that professionals often do not act in a way that will really empower parents. This problem seems to arise because of the concept many professionals have about their role in a parent guidance session. Many come into a session with general preset goals, rather than with the desire to focus on observing the parents and then deciding the needs of a specific parent-child relationship at a specific language learning stage.”
The prime target of early intervention in the family must be to empower parents. If the sessions succeed in restoring the parents’ confidence in relating to their child after having been shaken by the diagnosis, then this provides an ideal foundation for auditory language acquisition in everyday life. However, the professional cannot equip parents with this confidence if she talks to and plays only with the child herself to the extent that the parents or other caregivers are relegated to mere onlookers. This may even reinforce any self-doubts, as the parents may end up thinking, “I’ll never be able to relate to my child as well as this professional can!” The early-years practitioner must therefore be able to step back and observe the parents as they interact with their child – and not only how they play or look at picture-books together, but with a big emphasis on everyday activities like emptying the dishwasher, watering a plant or feeding the child. In this way, the professional can make parents aware of their very own individual strengths and tell them which types of interactive behaviour help the child in their development. It is also important to state precisely why such behaviour is valuable for the child at this particular stage of their development. In this way, parents discover that they are well able to provide the right developmental support, even for this child with his/her hearing impairment; to speak to the child in their very own individual style and to raise it in the way they think is right. And, as well as providing feedback on all the positive aspects of the interaction, certain facets of the child’s behaviour can be highlighted. In order that the parents remain confident in their child’s potential for development, it is very important to frequently highlight progress, however modest.
An example to illustrate this: Tim, 20 months old, who wears two cochlear implants, has a piece of paper in his hand that he shows his father. His father says to him: “That belongs in the bin.” The child looks at his father and his expression makes clear that he doesn’t understand what his father has said to him. The father offers the child his hand and says, “Come on, let’s take the paper to the bin.” The child takes his father’s hand and goes with him. Father: “Look, that’s the rubbish bin. Can you open it?” Tim looks at his father and says “Open!” Father: “Yes, open it and throw the paper in.” The father waits; the child does so and says “Closed!” The father praises his son and says: “That’s right, now it’s closed. Well done, you did great!”
Right from the beginning of this short scene, the father does exactly the right thing. He picks up on the child’s non-verbal contribution to communication and speaks to the child. When he realizes the child doesn’t understand, he doesn’t just take the paper from him and throw it away himself but involves him in the action, taking him by the hand. And, all the while, he ‘commentates’ on what is being done. This enables the child to hear the right words in the situation and thus progressively acquire to learn the meaning of the words. The father says what the rubbish bin is called when they are standing in front of it and again tries to stimulate the child’s language development. In this way, he encourages the child to listen. Tim already understands ‘open’ and can (through imitation) say the word. The father then also repeats the child’s utterance and thus endorses the child’s contribution. But he goes one step further: he amplifies what the child says by saying: “Yes, open it and put the paper in.” Then he stops speaking and waits. As already mentioned in Chapter 1, this is of crucial importance for fostering language skills and encouraging dialogue. If the father were to speak continuously in this situation, in order to comment on actions, give instructions or ask questions, this would not help make the child a more attentive listener; on the contrary, they would be overwhelmed with language and would quickly switch off and tune out. However, this pause means the father is giving his son the chance to carry out his action, formulate his own thoughts about it and to express them using language. For example, Tim proudly says “Closed!” The father had not previously mentioned this word. This means that – rather than merely repeating the word after his father (as with “Open!”) – he can already use this word independently and purposefully. He further follows up on this language contribution by his son in a way that, again, serves as validation.
To sum up, the way the father acts in this interaction scene very much serves to foster development. And, at the same time, he helps the child become more independent and his praise boosts the child’s self-confidence. By describing her observations, the professional can give the father a confidence-boost in his communication with his son, even if Tim is only just starting out on his hearing and language development and, for both of them, making themselves understood is not always easy. Obviously, the parents should not be showered with too many feedback points. It is always a good idea to single out just a few items and discuss these in detail. Would Tim’s father benefit from an additional tip? The professional could, say, draw his attention to the fact that praise for Tim would be even more valuable and linguistically useful if he specifies what he is praising, as in: “Great, you can already do that all alone!” or “Great, you can already throw away rubbish without any help!”
Whereas it used to be generally the case that the practitioner would bring the child interesting toys and herself encourage the child to listen and speak through play, her role now needs to be understood differently. She is no longer the ‘expert’ who shows the parents what form their child’s help needs to take, and the parents are no longer passive observers who are to copy this behaviour. Rather, the professional brings her experience and knowhow to bear in helping the caregivers relate to the child in their very own way.
In this, it is important that parent guidance is not restricted to play situations but deliberately incorporates the many everyday situations that continually come up. Observing the interaction and then discussing it are thus an integral part of every intervention session. Additionally, the professional herself also interacts with the child, provides ideas to augment the child’s own interests and ideas for play, and gives the parents sufficient time for their questions or to air anything else they want to. Also in the guidance of other caregivers outside the family, this concept offers real individual help because it analyses what parts of the interaction are already supporting the development, and what kind of additional advice is necessary.
An early-years practitioner must, of course, be generally aware of the limits to her own expertise and, as required, refer the parents to other capable professionals such as psychologists, social workers or self-help groups.
To close with, here are a few interesting statistics. Bender-Köber/Hochlehnert (2006) show that it can be easily documented that early-intervention sessions – on the grounds of time alone (quite apart from the relationship aspect) can never do the really crucial work in terms of the child’s development.
By the time it has reached the age of five, a child will have lived for a total of 43,800 hours, broken down as follows:
Time spent asleep: 19,800 hours = 45.8 %
Time spent awake: 23,400 hours = 54.2 %
in nursery school: 3,600 hours = 8.3 %
in early intervention: 318 hours = 0.7 %
in the family : 19.482 hours = 83.3%
The family – and all the other people who help look after the child on a day-to-day basis – hold the key to hearing and language acquisition by children with hearing impairment. It is thus the job of all professionals involved not only to provide the necessary medical and technical support but to offer ongoing individual guidance and assistance so that communication with the child, in everyday life and at play, ‘works’ as well as possible and that, above and beyond this, the child receives the help they need in developing their personality as a whole.
Early intervention for hard of hearing and profoundly deaf children:
a) takes place from the age of 12 months onwards as, before this, the children do not participate in specific developmental games;
b) takes place, during the child’s first year of life, only in the form of guidance sessions with the parents – the children are not included until later;
c) means, in terms of work with babies, that the practitioner passively provides as many sounds as possible so that the child learns to hear and the right neural pathways can be formed;
d) means primarily that the parents and other caregivers are supported in their communication with the infant and thus also in building the relationship.
With regard to technical provision for children with hearing impairment, the practitioner should:
a) undergo regular in-service training in order to be able to give the parents the capable guidance and support their need and work closely with the relevant professionals (such as hearing-aid acousticians, staff at cochlear implant centres and paediatric audiologists);
b) generally not provide any input on this as she is not qualified to do so;
c) supply the parents regularly with as much technical literature as possible, even if they do not ask for it;
d) first and foremost highlight potential problems in the use of this equipment.
During the sessions, the early-years practitioner should:
a) work alone with the child because this improves their concentration and takes the strain off the parents;
b) use interesting toys and objects that are not otherwise available to the child;
c) pick up on everyday and play situations that assume an important role in the child’s life, as this best ensures that the guidelines discussed are put into practice;
d) show the parents special noise-generating toys at every session and demonstrate how to use them.
The role of the early-years practitioner today consists primarily in:
a) empowering parents and other support persons and thus making it possible for the child to acquire hearing and language in everyday life;
b) serving as a model to the parents of how to relate to the child;
c) conveying to the parents that professionals can help their children better than they can themselves because they have the right qualifications and experience;
d) dealing, through discussion, with any psychological problems the diagnosis has triggered in the parents, such as depression.
Batliner, Gisela (2004): Hörgeschädigte Kinder spielerisch fördern. Ein Elternbuch zur frühen Hörerziehung. 2. Auflage, München: Ernst Reinhardt
Batliner, Gisela (2003): Hörgeschädigte Kinder im Kindergarten. Ein Ratgeber für den Gruppenalltag. München: Ernst Reinhardt
Bender-Köber, Beate, Hochlehnert, Hildegunde (2006): Elternzentriertes Konzept zur Förderung des Spracherwerbs. Handbuch zur Durchführung von Elternworkshops. Borgmann Media, Dortmund
Clark, Morag (2006) A Practical Guide to Quality Interaction With Children Who Have a Hearing Loss. San Diego: Plural Publishing
Horsch, Ursula (2007): Der ununterbrochene Dialog. In: Spektrum Hören 2007
Pöllmacher, Angelika, Holthaus, Hanni (2005): Auf einmal ist alles anders! München: Ernst Reinhardt