Raising and Educating a Deaf Child

International experts answer your questions about the choices, controversies, and decisions faced by the parents and educators of deaf and hard-of-hearing children.

Cochlear Implants and Hearing Aids

Is cochlear implantation useful for all profound hearing-impaired students?

Question from D.D., India. Posted January 22, 2013.
Response from Marc Marschark - NTID

Even at their best, cochlear implants do not change deaf children into hearing children, but they do help most children with profound hearing losses (in most countries, cochlear implants are available only to children with profound hearing loss). Importantly, there are large individual differences in outcomes among children who receive implants, and we are not very good at predicting outcomes for individual children. However, there are several factors that are associated with greater benefits:

• length of time since implantation (shorter is better)
• age at implantation (younger is better)
• degree of hearing loss (both in the implanted ear and the other ear)
• age at onset of hearing loss
• amount of language when hearing was lost
• parental support for the child and postimplant therapy
• children’s cognitive abilities, and
• the amount and types of postimplantation therapy received.

Some of these factors affect the level of performance achieved while others affect the speed of acquiring various skills, and both vary across children. An otolaryngologist (ear, nose, and throat doctor) and/or cochlear implant surgeon needs to give a child a complete examination before making specific recommendations and predictions of success. For more information, see Chapter 2 in Marschark, M. (2007). Raising and educating a deaf child, Second edition. New York: Oxford University Press.

I work with a deaf CI student with a cognitive (FS IQ 67 WISC-IV), as well as a speech and language disability. While we continue to work on phonological awareness skills and some phonics while reading, the student is proving to be mostly a sight word, or whole word, reader. This student is reading at the 1st grade level and has a sight word vocabulary of about 85 words. I am looking for a reading series or curriculum that would fit the student’s needs for a very pragmatic reading program which will build knowledge, language and vocabulary of common social and community content. The Edmark nor Milestones are a good fits, nor is the Fairview. The student (an “Only”) has some receptive sign skills, but is primarily oral.

Question from K.B., Vermont. Posted January 14, 2013.

In working with schools to implement phonics-based reading curricula with a variety of learners who are deaf or hard of hearing (including those with additional disabilities), I have found that some students initially struggle with understanding the abstract nature of phonology and benefit from starting with a sight word approach. A curriculum we have used in these cases is the PCI Reading Program. This research-based program contains three levels, the first teaches 140 basic sight words (primarily nouns and verbs) and the second focuses on an additional 140 more complex, sight words (compound words, inflectional endings) and introduces beginning letter-sound relationships. Finally, the third level bridges to a phonics-based approach. To learn more about this curriculum, I would recommend visiting the company’s website, which provides detailed information about the approach, a nice overview video, and a link to order sample lessons. http://www.pcieducation.com/reading/lvl1.aspx

I am from Turkey. My son has autism and was born with a profound sensorineural hearing loss. He was implanted at 5 years of age. He is now 12 years old.. He cannot speak or write. It seems there isn’t anybody else like him in Turkey and I cannot get any assistance in dealing with his multiple challenges. I want to teach him speak. How can I do that? How can I help my son?

Question from M.Y., Turkey. Posted September 27, 2012.

I am sorry to hear that you have not been able to access help for your son that you feel has been useful. Certainly deafness and autism each present their own challenges, but together things are much more complex.

Autism alone is associated with language impairments that are often quite significant. Many hearing children who have autism develop only very limited speech, and some only sounds, with no functional speech. The focus for these children should usually be on communication, not speech. This means trying to build communication of any kind, including gestures, manual signs, picture systems, as well as  speech — basically anything that allows the child a chance to communicate with the world around him. And an important part is trying to motivate the child to want to or need to communicate.

Your son also has a profound hearing loss. That is also by itself a high risk factor for acquiring speech. A cochlear implant may make speech sounds more available to him. But even if that were the case, he still may be affected by the language disorder I mentioned in connection with autism. So many, many questions remain that will impact on your son’s ability to speak and to write.

So the situation is complex. But does that mean there is no hope? Absolutely not! With appropriate and consistent support, most children make significant gains in many areas. If it has not already been done recently, I would recommend having an assessment done of your son’s intellectual, language and daily living skills, so you can understand where his skill levels are currently. Then try to find someone who can provide a program of systematic behavioral therapy, with a special focus on communication in as many activities as possible.

I don’t know the availability of services in your area, but hopefully a physician might know of available services, or the professionals who did the implant, or perhaps if there is  a university in your area. Did anyone provide you with support after the implant? That person may also be able to help connect you with services. Two sources that I am ware of online are:  The Tohum Foundation   http://www.tpfund.org/TOHUM/default.asp and The Gunsigi Services  http://www.gunisigichildtherapy.com/cigdem-ergul.php

Both, I believe, are in Istanbul, but hopefully they can connect you with services where you are located. The Tohum Foundation indicates their “ key purpose is to lead and disseminate early diagnosis, education, and social integration services for children with autism throughout Turkey.”

There is a family support group in North America that you should be able to access through   http://groups.yahoo.com/group/DEAF-Autreat   I have met some of these families, and they are wonderful people and many have struggled with similar concerns.

I have a son who was born deaf but has a cochlear implant. he doesn’t want to pick up on spoken language so im introducing sign language to him. He also has many developmental delays and was wondering what would be the best way to go about teaching how to sign.

Question from P.T., California. Posted September 19, 2012.

This is a tricky question, not one that can be addressed fully on this site. There are so many questions that need to be asked! Crucially, I would want to know things like: How old is the child? How long since he had his implant, and has he been wearing it consistently? Are you sure the technology is working correctly and that your son was mapped correctly? What do we know about these other developmental delays?

Importantly, we need to know what is meant by “doesn’t want to pick up on spoken language.”  This is an interesting and unusual way of phrasing this, and I would need to know how you have reached this conclusion? It is only with this sort of information that we can give you any clear advice. Plus, assessments describing the child’s progress or lack of progress from the pre-implant stage to now would be very useful indeed.

The next step would be to think about what you mean by sign language. To professionals this may be very clear, but to parents it can mean many different things. Are you looking to use signs to support spoken language? Or, are you looking at a whole new language? Using simple signs to support spoken English would be a great place to start. Learning a language like American Sign Language would require a big commitment from you and other family members. And, she would need to explore at length whether your child’s developmental delays might act as a barrier to language learning – sign languages are not an easy option!

I think you really need to talk to your local professionals, so the whole family can all think about what you are trying to achieve with your child and refocus on the goals. Importantly, if they tell you either that you must not sign with your son or that he will never achieve spoken language, you should look for another opinion. There is no “black and white” here, you are asking about a complex situation that likely does not have any simple answer.

Can you suggest criteria or guidelines for a speech-language pathologist in deciding amount and type of articulation services for an 11 year old, with a cochlear implant and with a cognitive disability (FS IQ 67)? He can produce all the phonemes in isolation but has many errors, deletions, and substitutions in connected speech. This student’s many needs all require large amounts of time and repetition (sometimes years) in order to develop, though we do see progress. In part the slow progress is because the student is complex (history, etiology, needs). In addition however, the student’s services and placement are not adequate to meet his complex needs; we work with it as best we can. The good news: I hope he will receive an evaluation at the Clarke School this spring. Meanwhile another year is ticking away.

My suggestion to the SLP was to embed articulation work within the pragmatic, social communication we will be focusing on this year. Suggestions or examples of what this more specifically might look like would be welcome since she is not trained in working with deaf and hard-of-hearing children.

Question from K.B., Vermont. Posted September 19, 2012.

In looking at your description of this child, his cognitive skills, age and current articulation skills, my first inclination is to ask whether a phonological analysis has been done on his speech production patterns?  I ask this because you say that he can produce all phonemes in isolation, (this is great!!!), yet he has errors in connected speech.  A phonological disorder is characterized by difficulty acquiring the rules that underlie the sound system.  A child with a hearing loss and cognitive issues would be at risk for this.  For example he may be producing phonological processes that are characteristic of a younger child, such as deleting final consonants (“home” is pronounced “ho”) or fronting velar sounds (“Kiss” is pronounced Tiss), or he could be displaying the process of stopping (substituting a stop sound for a fricative or affricate sound, so “Funny” is pronounced “Punny”). There are several tests that can assess whether the child is producing phonological processes – you might want to look into having an assessment done.

•     Bankson-Bernthal Test of Phonology

•     Clinical Assessment of Articulation and Phonology (CAPP)

•     Computerized Articulation and PhonoEval System

•     Hodson Assessment of Phono Patterns (Happ-3)

•     Kahn-Lewis Phonological Analysis (KLPA-2)

•     Phonological Process Analysis

•     Smit-Hand Articulation and Phono Eval (1997)!

•     Structured Photographic Articulation Test

The other issue I wonder about given your description is whether he has apraxia, a motor programming issue, and a good test that checks for apraxia is called the Kaufman Speech Praxis test. The website provides other tests http://www.apraxia-kids.org/site/apps/nl/content3.asp?c=chKMI0PIIsE&b=788447&ct=464141

I see that he has an evaluation coming up at Clarke and that will be great, but in the meantime, it would be valuable to know whether he has characteristics of either apraxia or a phonological disorder.  I say that because these types of disorders do not respond well to traditional therapy methods, and for these he will need direct targeting. It would be important to begin adapting his therapy plan accordingly.  The “Cycles” method can be very effective in treating either issue and even for children with hearing loss.  A typical session in the “Cycles” method goes like this:

•     Review past session

•     Auditory bombardment

•     Target word cards (adapt with photos, or photos with words printed under them and take vocabulary from his units in school )

•     Production Practice with different activities every 5-7 minutes

•     Stimulability probes

•     Auditory bombardment

•     Home Program

Best of luck!

My almost 9-month-old niece is deaf and will be getting her first cochlear implant soon. Her mother has been researching the three implant brands but has not been able to get many professional opinions to help her decide which to choose. Any thoughts?

Question from S.H., Massachusetts. Posted August 17, 2012.

Professionals may or may not have their own “favorites” when it comes to the top-three implant brands.  Some will tell you straight out, and some do not feel comfortable making a recommendation of one implant over another. Each company has had its ups and downs with regard to factory recalls and product integrity. For some children, there are anatomical differences with regard to the cochlea (in the case of cochlear malformations or bony growth) that make one internal device preferred over another. For example, Med El offers a split electrode array that can be preferable when there is an anomaly. Certain life-styles warrant a specific choice in design feature. Cochlear Corporation and Advanced Bionics offer a “splash proof device.”  I would have a frank conversation with the surgeon and the audiologist who will be programming the device and ask them these questions:  1. Which device has been the most reliable in your experience? 2.  Which device have you had the most experience with? 3.  Which company provides the best support with regard to customer service, repairs, and warranty?  4. Are there any conditions specific to my child that makes one device better? 5. Is there a specific device that has an advantage given how young my child is?  Finally, I would ask the audiologist to give you a brief demonstration of the external device parts (how the device turns on, how the processor works with regard to volume and programs, how the headpiece looks and fits).  After you have seen and heard all this information, it is likely that one device will stand apart to you and that it will feel like the right choice.

My 17 month old daughter will be having her second CI soon. Her therapist recommends that she only listen and NOT sign or use hervision. I want her to know how to sign as well as use her CI. I am trying to teach her as I learn. I have bought several books but i feel like I should learn from a person not a book/ dvd but I’m having trouble finding someone to teach me in my area. Do you know of anyone in my area that teaches sign language?

Question from C.W., Georgia. Posted June 22, 2012.

Specifically for your area, West Georgia College is likely a good place to find continuing education courses, including American Sign Language. More centrally, however, if your daughter is 17 months old, she should be in the Georgia PINES project (parent infant network). The PINES teacher would be able to help you both her learn signs. If she is not already in PINES, you can get more information at http://www.gapines.info/whatmodels.htm.  PINES also offers a deaf mentor project so you should have the opportunity to work with and learn from a deaf mentor.

I had an audiologist tell me that 99% of the time when you add sign support to an implanted student the language level/development drops. I respectfully disagreed – Your thoughts?

Question from R.S., California. Posted May 17, 2012.

Thoughts aside, there is no published evidence we know of to indicate that this is the case. You might recommend the following to the audiologist: Spencer, L. J., Gantz, B. J. & Knutson, J. F. (2004). Outcomes and achievement of students who grew up with access to cochlear implants. Laryngoscope, 114, 1576 –1581. They found that high school students with implants who also had sign language interpreters in the classroom were performing at a level comparable to their hearing peers, a result normally not obtained with longer-term use of implants by students without sign language support.

I am the parent of a 17 year old male with a Nucleus 24 cochlear implant. He signs and speaks and has been going to a great high school, but is having difficulties in his reading and comprehension. He is currently reading around a 6 grade level. Are there any programs you would recommend to bring his levels up? I am being recommended Fariview (total communication) and Linda Mood Bell (oral only) by different sources and they are completely different from one another.

Question from E.D., California. Posted May 3, 2012.

Congratulations to you and your son for all of your diligence with reading.

Does your son read 6th grade text fluently (between 120 and 150 words read orally per minute) and accurately  (decoding 95 to 100 percent of the words or about one error for every 20 words)?  Fluent reading does not mean reading fast but your son should use a speed for reading that reflects the mood and expression of the text.  If he reads in a slow and labored manner, he will have difficulty comprehending text.  There are some programs that focus on fluency (i.e. Read Naturally) but your son would need to have the auditory ability to distinguish the text read orally and then try to copy that text.  Often times though enhancing background knowledge, vocabulary and comprehension strategies fluency increases.   Repeated reading and some practice with chunking words into phrases have shown some success.

Once someone reads at the sixth grade level they tend to already be able to decode but have difficulty with more complex vocabulary and language structures.  At http://www.meadowscenter.org/vgc/downloads/special_ed/SEDsecondaryoriginal/2000_enhance_read_2_SE.PDF  there are wonderful resources from the Vaughn Gross Center for Reading and Language (through the University of Texas at Austin) that provide strategies for all parts of the comprehension process (from activating prior knowledge, to monitoring and using repair strategies, summarizing, using  visual imaging, asking questions and reflecting on the text).

Not knowing your son it would be hard to pick where to begin but ask yourself if he can decode words well (recognize the printed word)
-  if yes don’t spend time teaching sound symbol
-  if he struggles with the sounds of words and decoding, Lindamood-Bell and other companies have some great programs (LIPS, Seeing Stars) that may be of benefit.

Can he only say the words but not understand the meaning of the words?
-  then lots of language
-  possibly bits of Fairview may be a tool to help with understanding the various sign meanings (concepts) of different sight words)
-  pre-expose to a variety of text specific words, concepts and there meanings

Does he read words quickly enough to make meaning from the words he reads?
-  rereading, or partner reading
-  chunking and phrasing of text
-  Read Naturally or possibly Vocaroo (can record online)

Does he engage himself in the reading process by using comprehension strategies while reading?
-  If he decodes at about the 6th grade level, I would focus on text based vocabulary and comprehension strategies.
-  He should be able to establish a purpose for reading, see the text structure and begin to ask the right questions to aid in comprehension.

Developing the type of academic language and vocabulary necessary to succeed although daunting can be done.  Three cheers for encouraging your son and keep up the great work.

 

I have a question about personal FM system compared with soundfield. Our school district says that our daughter 3 years old is too young to give accurate feedback on if the Fm is working properly so they do not advice us to use it. Our daughter has severe hearing loss, uses hearing aids both ears, but tests low average on language skills as of now. No other concerns. We will be transitioning into the school system soon. They have a self contained class room with soundfield but we feel that a regular setting is least restrictive for her and want to find out which system to ask for in that setting.

Question from A.R., Florida. Posted March 16, 2012.

I am absolutely flummoxed at the school district’s position, and cannot think of one piece of evidence to support their recommendation.   The FM is an excellent solution in this case. The personal FM has a ‘boot’ which fits onto the individual’s personal hearing aids.  The teacher wears a microphone and transmitter, and the teacher’s voice is transmitted directly to the child’s hearing aid.  The statement that a three-year old is not able to tell if the FM is working correctly makes no sense, because the child is wearing a hearing aid and the child either has the skills to indicate the hearing aid is working correctly or not.  The same premise of operation will be at work with the FM system.  Infants can use FM systems, infants wear hearing aids, CIs and we all learn to read their behavior to assess whether the system works correctly and eventually the child becomes an accurate reporter. I  worked in a preschool classroom where all the 3-year olds used personal FM systems.  The FM system can and should be given a “listening check” each day.  The FM system will allow your child to be placed in a most appropriate environment.  It will cut down on background noise and give her a ‘direct link” to the teacher’s voice, where a sound field system will not.

There are several websites that can inform the district personnel how to do daily listening tests on the hearing aid and the FM system.

http://www.pepnet.org/faq/faq02.asp

http://www.asha.org/docs/html/GL2002-00010.html

http://www.phonak.com/