Maximizing Auditory

and Speech Potential for

Deaf and Hard-of-Hearing
Children

Maximizing Auditory and Speech Potential

for Deaf and Hard-of-Hearing Children
Good morning, and thank you for asking me here today to talk
about maximizing auditory and speech potential for deaf and
hard-of-hearing children.

Slide 1

Early Intervention
Early identification and intervention are the most important
factors for maximizing auditory and speech potential for deaf
and hard-of-hearing children.
As you will learn today, the first six months are crucial. Children
whose hearing loss is identified by six months of age develop
significantly better language skills than children identified later.
Slide 2

They achieve more academically and they have an easier time

functioning in society. Many can manage their day-to-day
interactions independently, without the help of an interpreter.

Course Objectives
Today well cover a lot of territory about hearing loss in children.
You may be surprised to know that congenital hearing loss
affects between 1 to 3 per 1,000 live births, making it the most
common anomaly in newborns.
Well discuss the profound impact of hearing loss on the childs life,
as well as review the wide range of interventions now available.
Slide 3

Perhaps most important, well talk about the communication

options available to deaf and hard-of-hearing children, and how to
maximize a deaf or hard-of-hearing childs ability to listen and speak.
Many parents and professionals have assumed that the only option
is sign language, and do not know that almost all deaf and hard-ofhearing children can learn to listen and to speak through oral deaf
education, which gives them many advantages in a hearing world.
It is important to note that 90 percent of deaf children are born to
hearing parents.

Facts: Hearing Loss Incidence

As I mentioned, hearing loss is the most common birth anomaly.
Occurring in 1 to 3 per 1,000 live births, its 20 times more
common than phenylketonuria, for which newborns are routinely
screened. It is twice as common as phenylketonuria,
hypothyroidism, sickle cell disease, and galactosemia combined.

Slide 4

Hearing loss also occurs after birth due to causes including

autoimmune inner-ear disease, meningitis, maternal viral infection
during pregnancy, or ototoxic drugs given after birth.
Despite the frequency of hearing loss in children, many pediatric
professionals are unaware of the advances in hearing testing,
technology, and the many communication options available to
deaf and hard-of-hearing children.
A survey conducted last year found that while half of pediatricians
had heard of oral deaf education, only 30 percent were aware of
programs in their community. More than 90 percent believed that
sign was the primary method used by deaf and hard-of-hearing
children to communicate.

Facts: Risk Factors for Hearing Loss Birth to 29 days

What causes hearing loss?
In about 50 percent of all cases, the cause of a childs hearing loss is
not known or identifiable. Risk factors include:

Slide 5

Known genetic factors in 25 percent of cases. However, most

genetic deafness is recessive and 90 percent of deaf and hard-ofhearing children are born to parents who have normal hearing.
In utero infections such as cytomegalovirus can cause hearing loss.
Other anomalies are associated with deafness, including craniofacial
anomalies.
Birth weight under 3.3 lbs
Hyperbilirubinemia requiring exchange transfusion
Ototoxic medications
Apgar scores of 0-4 at 1 minute or 0-6 at 5 minutes
When any of these risk factors are present, the childs hearing
should be screened immediately, and in the presence of some
factors, tested at 6-month intervals until the child is 3 years of age.
Of course, it is always recommended to test all newborns because of
the benefits of early intervention.

Facts: Risk Factors for Hearing Loss 29 days to 2 years

Slide 6

Parent/caregiver concern regarding hearing, speech, language,

and/or developmental delay
Bacterial meningitis and other infections associated with
sensorineural loss
Head trauma associated with loss of consciousness or skull fracture
Stigmata or other findings associated with a syndrome known to
include hearing loss
Ototoxic medications
Recurrent or persistent otitis media with effusion for at least 6
months
Family history of hearing loss

Facts: Diagnosis and Intervention Lag

Although hearing loss is the most common birth anomaly,
universal screening has only recently begun in some states. As a
result, babies are often 1, 2, 3, or even 4 years old before they are
diagnosedon average 13-22 months of age, depending on the
severity of the loss.

Slide 7

Parental concern is a very important clinical indicator that there is

a problem, and should be taken as seriously as any other risk factor.
Often there is a lag of several months after parents bring their
concern to a physician before the physician tests the childs hearing.
Physiological tests of hearing can identify and diagnose infant
hearing loss very early. No child is too young to have a hearing test.
The lag in diagnosis and treatment can have serious consequences
for the child.

The Case for Early Diagnosis and

Intervention
Some of those consequences include damage to the parent-child
bond and behavioral problems, as well as delays and problems with
language acquisition.
Lets look at these in more detail.
Slide 8

The Case for Early Diagnosis and

Intervention
A child with hearing loss does not respond in the same way as
hearing children do. For instance, he or she may not turn toward
people who are talking to him or her. When the hearing loss has
not been diagnosed, parents and other people often interpret this
as an emotional problem instead of a physical problem.
Slide 9

Parents may assume problems with the relationship, with

their parenting, or with the childs emotional style instead of
suspecting hearing loss.
A hard-of-hearing or deaf child may use hitting or aggression to get
a point across or gain attention, or out of frustration at being
unable to communicate. Some children may withdraw as a result
of a lack of communication skills.
If not diagnosed until the child is 2 or 3 years old, the emotional
and social damage can be longstanding.
Ironically, the child most likely to be diagnosed and treated is the
profoundly deaf child. Yet the child with mild to moderate hearing
loss may suffer the same issues and bonding problems.

The Case for Early Diagnosis and

Intervention
Early childhood is a critical time for language development, but
until recently we didnt realize HOW early and HOW critical. As it
turns out, the first 6 months are perhaps the most important.

Slide 10

To determine whether early intervention with children with hearing

loss made a difference in language development, Yoshinaga-Itano
and colleagues from the University of Colorado compared the
receptive and expressive language abilities in children with hearing
impairment with those of children with no hearing loss.
The study found that scores were significantly higher when the
children were diagnosed and intervention started before 6 months
of age.
This is reflected in the Yoshinaga-Itano results charted here.

The Case for Early Diagnosis and

Intervention
What was particularly striking in the Yoshinaga-Itano study is that
in children with normal cognitive abilities, the statistical difference
was independent of age, gender, ethnicity, communication mode,
degree of hearing loss, socioeconomic group, or the presence or
absence of other disabilities. The only meaningful difference was
the age of diagnosis and intervention.
Slide 11

Those first 6 months give the child the chance to develop language
normally, instead of playing catch up.

Screening Protocols
Because hearing loss is the most common birth anomaly, and
because early intervention is so critical for language development
and socialization, every hospital should institute a universal protocol
to screen for hearing loss.

Slide 12

Universal screening can be conducted for less than $30 per baby,
including hardware cost, disposables, and the screeners time to
conduct the test.

Screening Protocols

Slide 13

Routine newborn screening is not the whole story, however.

Genetic hearing loss may not be present at birth, but may develop
in the months after.
And as we discussed earlier, other causes, such as hearing loss due
to ototoxic medications, can occur later. So there are other times
when children should be tested.
Parental concern should be considered a valid factor that there is
a hearing loss, and a child should be tested immediately if the
parent suspects a hearing problem.
If there are risk factors such as family history or low Apgar scores,
the child should be tested even if there are no obvious other
symptoms.
If there is a question about the results of initial testing, additional
tests should be scheduled at 3- or 6-month intervals.

Auditory and Language Milestones

An infant who has tested normally, but who misses major
developmental milestones should be tested again.
Newborns should startle to loud and sudden sounds.
By 2 to 3 months, the child should laugh, form sounds in the back
of the mouth, recognize familiar voices, and distinguish changes in
tone of voice, for instance, a question or a happy statement.
Slide 14

A child of 4 to 6 months ought to turn his or her head toward a

sound to find the source. The child also should start making
syllable-type noises, putting vowels and consonants together,
and simply make noises of all types.

Auditory and Language Milestones

At 6 to 12 months, the child should be babbling, repeating
syllables like ma-ma-ma, and using pointing and facial gestures
to communicate.

Slide 15

A 12-month old may only be speaking a few words, but should

be playing with sounds to make adult-like speech patterns, and
typically understands 50 words or so. The child should know
his or her own name, understand no, and understand
simple directions.
Between 18 months and 36 months, most children experience
very rapid development of speech. By 3 years, a child will know
thousands of words, make short sentences, and sing songs.
Children who miss these milestones should be tested again for
hearing loss.

Screening Protocols
Taking immediate action when you suspect a hearing loss is
important because every day missed is a day that language
acquisition is affected.

Slide 16

As soon as a screening indicates a problem or you suspect a problem,

the childs hearing should be thoroughly checked by an audiologist
with pediatric training. The audiologists pediatric experience is
essential, because testing children and infants is very different from
testing adults who are losing their hearing, and requires special
training.
When hearing loss is identified, a medical work-up, usually
performed by an otolaryngologist, should occur to determine
cause and possible treatment options.
Hearing aids can and should be prescribed and fitted as soon as the
hearing loss is diagnosed, even on tiny newborns. There is no benefit
to waiting. Hearing aids alone are not a quick fix. Parents and
professionals need to work closely with children to help them
make sense of sound.
Parents also need time to mourn, adjust, learn, and immerse
themselves in the skills and knowledge theyll need. Some period
of adjustment is to be expected. However, parents who hesitate for
more than a month or two may need help to get moving, because
their denial can have long-term consequences for the child.

Audiology
The audiologist uses a range of tests, often over a period of months
or years, to pinpoint the exact type and severity of hearing loss.
Some of these are passive tests that can be administered without
active participation on the childs part. Some tests must be postponed until the child is old enough to respond actively.

Slide 17

Severity of hearing loss is classified as mild from 25-40 dB,

moderate 41-70 dB, severe 71-90 dB, and profound is anything
more than 90 dB. The audiologist can also identify which
frequencies are affected.
Profound loss does not mean total absence of hearing, which is in
fact very rare.

Audiology
Passive tests are ideal for small children because they dont require
cooperation. These tests can be conducted on children as early as
one or two days after birth.

Slide 18

Auditory Brainstem Response (ABR) uses electrodes to test an

infants brain response to a series of sounds including different
frequencies and clicks. Babies older than 4 months may need
sedation, not because the test is painful, but to keep them still.
ABR tests the entire auditory pathway.
The Otoacoustic Emission (OAE) test uses a probe to measure
echoes from the inner ear in response to sound. A normal cochlea
creates its own sound in response to sound entering the ear. OAE
tests this function of the cochlea.
Tympanometry measures the movement of the eardrum and the
ability of the middle ear to conduct sound to the inner ear.
Acoustic reflex tests for a normal reflexive response to loud noises.

Audiology
The active tests of a childs hearing require special training and skill
on the part of the audiologist to interpret and understand the
childs reactions.
In Behavioral Observational Audiometry (BOA), the audiologist
watches the babys face and changes in behavior in response to a
series of sounds.
Slide 19

In Visual Reinforcement Audiometry (VRA), the audiologist

directs the child to a toy that lights up or moves when the child
looks at it in response to a sound.
In Play Audiometry, the audiologist teaches the child to respond
with a particular action when he or she hears a sound.
All of these tests are done with speech sounds and pure tones at
different pitch and loudness levels to obtain the most complete
map possible of the range and severity of the childs hearing loss.

Audiology
This familiar sounds audiogram is designed to explain a childs
hearing loss to families in terms that they can better understand.
It is used to show the frequencies affected and the severity of the
loss, as well as what the aided potential is with hearing aids.

Slide 20

Hearing Technology Today

Hearing technology has improved dramatically in the past 10 years
and continues to become more powerful and sophisticated.
Even profoundly deaf children can benefit from hearing aids today,
whereas 20 or 30 years ago, the available aids often did not provide
enough amplification. In addition, todays aids can be tuned to the
childs specific hearing profile.
Slide 21

The range of options for different children and different situations

includes hearing aids, FM systems and cochlear implants, each of
which well review in greater detail.
The critical point to remember is that even though it is powerful
and effective, the technology is not a solution by itself. Hearing and
speech must be taughtthe technology does not make hard-ofhearing and deaf children into normal-hearing children.

Hearing Techology Today

Hearing aids work like tiny amplification systems. They receive
sound and amplify it at each frequency to make the most of the
childs residual hearing.

Slide 22

Hearing Technology Today

Fitting children with hearing aids is not a one-time event.
It takes time and patience.

Slide 23

Since the patients are generally pre-verbal, observation and deduction

will be required. The audiologists observations at the childs
appointments are important, but time-limited. Therefore, the
parents ability to notice and discuss the childs response is
important in fitting aids. Encourage parents to take notes and
bring them to appointments.
Parents may need to work with several different types of aids over
time to find the one that works best for their child. A daily, weekly,
and monthly maintenance routine is important to ensure that
young children are getting the benefit of the aid. Batteries go bad,
peanut butter gets in the amplifier, cords break, etc. At any given
time, only half of small childrens aids are working.
Children may find aids distracting or try to take them out at first.
Parents may feel embarrassed or experience emotions and need to
process these normal feelings.

Hearing Technology Today

There are three basic types of hearing aids and many variations
among them. There are benefits and drawbacks to each, and
different aids may be appropriate for different children.
Analog aids can be made more powerful than digital aids, and are
often the best choice for profoundly deaf children. However, they
make some static noise even when its quiet, which can be
distracting for children with mild hearing loss.
Slide 24

Programmable aids are easier to tailor to a childs hearing profile

than conventional aids are.
Digital aids offer the most precise control, and are silent when its
quiet, but they are not as powerful as analog aids, so they may not
be ideal for children with the most profound loss.
The services of an experienced pediatric audiologist are required to
recommend the appropriate amplification device.

Hearing Technology Today

FM systems consist of a wireless microphone that is worn by one
personusually a parent or teacherthat transmits sound to the
child, who wears a receiver. FM systems overcome problems of
difficult listening situations, such as a noisy environment or
a distance.
FM systems can work as a hearing aid, and also focus and clarify
the sound of the speaker using the microphone consistently.
Slide 25

FM systems can be very useful when a baby is little and needs

access to consistent sound to learn to use the sense of hearing.
They are traditionally used in schools to overcome the noisy
classroom environment.

Cochlear Implants

Slide 26

Cochlear implants offer dramatic benefits to many children whose

hearing aids dont supply sufficient amplification to learn to develop
spoken language efficiently. Different from hearing aids that amplify
sound to the middle and inner ear, cochlear implants send electrical
signals directly to the inner ear and stimulate the auditory nerve.
This is accomplished by surgically implanting an electrode array
in the cochlea. The external component of the cochlear implant
consists of a headpiece with a microphone and a speech processor
(usually body worn).
The speech processor converts acoustic information entering the
microphone into electronic codes, which are then transmitted
through the skin to the implanted cochlear stimulator and onto the
electrode array. The electrodes stimulate the nerve endings within
the cochlea, which send a stimulus to the brain and is interpreted
as sound.

Cochlear Implants
Children may be candidates for cochlear implants if they have a
bilateral severe to profound hearing loss, and have received marginal
benefit from their amplification after at least six months of use.
As we learn more from the success of the earliest implants, cochlear
implants are becoming more common in younger children.

Slide 27

Cochlear implants are FDA-approved for children 12 months and

older, although there are now many cases of children receiving
cochlear implants as early as 9 months of age.

Communication Options
Although American Sign Language has developed a high profile
over the past decade, there are other communication options for
the deaf or hard-of-hearing child that parents and professionals
must be made aware of.
Today, deaf and hard-of-hearing children have options, including
learning to listen and speak.
Slide 28

Parents have the ultimate responsibility and the right to choose the
communication option that they feel is right for their child and
their family.

Communication Options

Slide 29

Auditory oral and auditory verbal are two slightly different

methodologies with the same basic goal: to enable deaf or
hard-of-hearing children to learn to listen and speak and
function independently in a hearing world. Both make use of
available technologies to aid the childs ability to listen, always in
conjunction with a comprehensive education program that is
developmentally appropriate for the child. Ill discuss them today
using the term, oral deaf.
Oral deaf education also focuses on the cognitive domain of each
child in order to promote thinking skills. All of these domains will
greatly enhance the childs educational future. Studies have shown
that spoken language acquisition has a positive effect on literacy.
Oral deaf educators teach children listening, speaking, and thinking
skills in addition to academic topics. They also teach parents, family,
and friends how to interact with the deaf or hard-of-hearing child
to support language development through strategies that enhance
listening and speaking.

Communication Options
Cued speech is intended to help the deaf person by providing visual
cues from the speaker for the sounds they are producing as they
speak. These cues help to clarify what is being spoken. The cues
are not sign language, and have no meaning without the verbal
context, but clarify the specific sound being made.

Slide 30

Communication Options
Total communication combines auditory training with Signing
Exact English, or SEE. SEE is a manual code for English that has
the same vocabulary and syntax.
Total communication has a disadvantage in that most hearing people
do not understand the signs, so it may limit the childs ability to
communicate with the hearing world.
Slide 31

Communication Options
ASL is sound-free. It is its own language, with unique syntax and
grammar, communicated by gesture and facial expression, and it is
not English.
Some people advocate teaching ASL over spoken language because
it is more natural or easy for the deaf or hard-of-hearing infant to
learn. There is a large pool of ASL speakers, including resources at
schools and universities.
Slide 32

ASL is not spoken or understood by most hearing people, which

poses a challenge to the ASL speaker who wants to simply buy a
hamburger or ask directions.
In addition, because literacy is based on auditory, rather than visual
pathways, it is more challenging for speakers of ASL to learn to
read, and literacy among ASL speakers has historically been low.

Oral Deaf Education: Team Approach

The success of oral deaf education depends on the skills and
cooperation of an extended team of professionals, family,
and friends.
The child and family are at the core, doing the daily work of
improving listening and verbal skills, and choosing and
managing the rest of the team.
Slide 33

The pediatrician and ENT specialist have roles in monitoring the

childs auditory health in addition to other health issues of childhood.
Audiologists and speech pathologists provide specialized technical
expertise in diagnosing and treating the hearing loss, and working
with the child and his or her parents to develop listening skills.
Oral deaf educators use specialized teaching techniques to teach
language skills along with academic subject matter.

Oral Deaf Education

Social interaction is the motivation every child has to learn and grow.
All family and friends should be invited and taught the skills they
need to communicate with the deaf or hard-of-hearing child.
Siblings can be excellent motivators and teachers. Grandparents
may have time and patience to share.
Slide 34

Involving the entire family not only is good for the child, but also
gives the parents a much-needed break.

Oral Deaf Education

Though many pediatricians have deaf or hard-of-hearing patients,
few know the options for children with hearing loss. A recent study
found that 90 percent of pediatricians believe that the primary
modality is ASL. Only about 1 in 3 knows of oral deaf resources in
their community.
Its important to have those resources ready, because parents will
turn to you for referrals.
Slide 35

The ENT specialist is essential in the diagnostic process,

determining cause and possible treatment options and working
with the pediatric audiologist to provide the appropriate
amplification device to maximize the childs listening potential.

Oral Deaf Education

The pediatric audiologist is the testing and hearing technology
expert. As we discussed, audiologists can pinpoint the degree of
hearing loss and the frequencies that are affected. Audiologists
work with families to find the right hearing aids and to fine-tune
them to the childs needs.

Slide 36

The speech and language pathologist teaches the child the skills he
or she will need to listen, attach meaning to sound, and develop
speech skills. These professionals also work with parents and family
to teach effective communication skills for use with the child.

Oral Deaf Educators

Oral deaf educators teach the whole child at each developmental
level, while supporting speech, listening, and language acquisition
and preparing the child for regular education. When appropriate,
oral deaf educators teach all academic subjects and prepare children
to move into mainstream schooling.
Oral deaf educators are often one of the best networking resources
for parents.
Slide 37

Conclusion: Remember These Key Points

As pediatricians, what do you need to remember?
Hearing loss is the most common birth anomaly by far, and
has enormous consequences for the child. Advocate for
universal testing at your facilities.

Slide 38

Children can be tested in the first days after birth, and hearing
aids fitted immediately. Research shows that there is an
enormous benefit to intervention before 6 months of age.
Technology does not fix hearing. Technology gives the child the
best opportunity to listen and develop spoken communication,
which must be supported with the right education over time.
Even children with profound hearing loss can learn to listen
and speak and communicate with hearing family members,
friends, and peers.

Conclusion (For physician audience)

You may be the parents first or only source of information about
oral deaf education. Make a point to keep a file on resources such
as pediatric audiologists, oral deaf educators, and speech therapists
so that you can help your patients achieve all they can.

Slide 39

Conclusion (Alternate slide for

non-physician audience)
You may be the parents first or only source of information about
oral deaf education. Make a point to keep a file on resources such
as pediatric audiologists, oral deaf educators, and speech therapists
so that you can help your patients achieve all they can.

Slide 40