Why is it important for kids with hearing loss to learn to use audition? One of the things we know is that phonics are a basis of literacy. Children learn to read by making sound-symbol associations and then sounding out words. Children learn that the sound /b/ is in the sound at the beginning of the word ball. If they learn what an /a/ sounds like and what an /l/ sounds like they can put the word /b-a-l/ together.

We know that the younger the child, the more cortical real estate. Younger brains are more plastic then older brains. Early language skills are the foundation for reading abilities. The more words a family uses in speaking to a child, the larger the child’s vocabulary. We know that reading difficulties contribute to academic difficulties. A child’s reading proficiency at 3rd grade is a significant indicator of academic success.

A typical hearing child learns about 10 new words each day. What does it take to learn 10 words a day? For a child to learn 10 words/day they need to hear lots of words in a day – they need to have good auditory access. A child’s listening vocabulary will lead to a child’s speaking vocabulary, which leads to a reading vocabulary, which leads to a writing vocabulary. To quote Dan Ling “The better they hear, the better they learn.”  What can we do to help the hearing impaired children we work with learn the language they need to develop literacy?

So what has to happen?

First you have to hear, then you can learn to use hearing to listen. Once a child is listening, then they can start to use listening to understand. And when they begin to understand then they are ready to use language, to build phonics skills and to develop literacy skills.

What can we do to help our children learn to develop these skills?

  1. Those of us working with children need to be vigilant in helping to focus them to listen. Point out sounds around you and help children to focus on sounds around us. Listening first.
  2. Talk, talk, talk about everything that is happening – what they are doing, what they are eating, what is happening as they go for a walk. When I walk down the street and see parents or nanny’s walking down the street with children but not talking to them, it takes everything I have not to scream at the adults. Talk talk talk.
  3. Kids need practice to learn to talk and respond. Give them a turn – a chance to respond. It is easy to fill in words when we ask kids questions. Don’t answer for them. Just pause, give them a chance to respond. If they do not, answer, but next time, give them a chance again to fill in. It helps if there are two adults, or an older child, who can be good models for language. Just keep providing demonstrations and kids will get it.
  4. Try to control the listening environment. Turn off TV, radio, dishwasher so that it is quiet and the child has the opportunity to learn to listen and learn. Several things affect perception. It is easier to hear when close, so start close and build skills when close. As children develop skills you can increase the distance. And when working on more difficult skills come close again.
  5. The auditory sandwich. Remember we are building listening first so we should be asking kids to listen. If the child cannot understand using listening, provide some visual input, and then repeat using listening to help the child build listening skills. Listen, look, listen. Sometimes I do listen, listen, look, listen, just to give a little extra change to listening.
  6. Work to expand language skills. If a child says “more milk” we need to expand the sentence. “Do you want more milk? I like milk. I want more milk. Should we get milk from the refrigerator?
  7. When a child does not respond, let’s not assume that they really did not hear. They may not feel confident in what they heard but let’s give them a chance. Ask them what they heard. What did you hear? What do you think I said?
  8. And Read Read Read. It is a wonderful way to provide language, to discuss things present in the books, including story lines, feelings etc.


We can provide children with hearing loss with lots of language stimulation. We can provide exposure to all kinds of experiences that provide lots of language, Let’s just remember that the more auditory language we expose children to, the more opportunity they have to learn auditory language, and the more auditory language they learn them better the chance of developing good literacy skills.

Why do some kids with hearing loss do poorly? Well, there are likely as many reasons as there are kids who do poorly. And there are likely as many solutions.


What is required for success?

For children with hearing loss to be successful they need to have language and literacy at age level. What does it take to get there? For children to succeed in language and literacy they need to have sufficient exposure to clear language. They need to hear every hour that they are awake. (Eyes open, ears on.) Parents need to understand the importance of language stimulation and need to know how to expand on language to provide their child with a rich language environment.


How much exposure does a child need?

Hart and Risley say typical hearing kids hear 46 million words by age 4. Dehaene says it takes 20,000 hours of listening to learn to read. Gladwell says children need 10,000 hours of practice to learn things. How will we get young children to meet these goals?


We need the following (at a minimum):

  • Early identification
  • Early and appropriately fit technology monitored daily
  • Intense language exposure
  • Educational programs willing to make adaptions
  • Ongoing monitoring


What goes wrong? (The short list)

  • Children missed during newborn screening or has a hearing loss that is not present at birth
  • Families do not follow-up as recommended
  • Technology is not fit early
  • Technology is not set to allow the child to hear soft speech
  • Child not using technology
  • Child not receiving auditory based therapy
  • Family not providing intense language stimulation
  • Child has other disabilities that interfere with learning


Can we fix it?

If a child does not get identified in infancy we cannot do much about that. It is beyond our control. We can only pick up when the child is identified.


When families don’t follow-up

Audiologists and pediatricians have a very big responsibility when families do not follow up as recommended. We all need a system in which we know which children failed newborn screening and/or follow-up testing and we need a way to find and follow-up with those families. Hearing loss in children is a neurological emergency. If a family does not follow up there is a reason. Do they not understand that hearing loss is a neurological emergency? Are there social concerns with identifying a child with a disability? Is the family in a financial situation which makes it difficult for them to follow-up? Audiologists need to get involved, or we need to get social services involved and we need to help families both understand the need to follow-up and help them succeed.


Is technology fit to provide sufficient auditory access?

Audiologists are responsible for assuring that infants and children are fit with technology so that they are receiving auditory information sufficient to provide auditory access for all speech information. In addition to verification, it is essential that, audiologists perform validation to assure that children have aided thresholds at 20-25 dB and speech perception scores which are good (80-89%) or excellent (90-100%) for normal and soft conversational levels in quiet and in competing noise. See my last post  (Is This Child Hearing Well Enough? http://hearinghealthmatters.org/hearingandkids/?p=2161&preview_id=2161&preview_nonce=a38376d1d3&_thumbnail_id=-1&preview=true)


Child Not Using Technology

If a child is not wearing technology we need to try and understand why. If only telling a child and parent to wear technology ensured that children would use hearing aids there would be no problem. There are lots of reasons why children might not be using technology. Parents may be uncomfortable with the technology, they may have problems accepting a child with a hearing loss. There may be family issues with grandparents not accepting a child with a disability. Parents may not feel optimistic about what is possible for a child with hearing loss and may not be able to do the work needed. Parents may not understand the need for full time technology use and intensive language stimulation.

Children may refuse to use technology for several reasons. If a child is not doing well first assume it is the technology, first assume it is the technology. My basic rule is if a child hears well with his technology, he will want to wear it. If a child does not want to wear his technology, I first have to worry about whether he is hearing well with it. If it not sufficient loud and the child cannot hear with it, there is no reason for a child to wear the technology. If the technology is too loud, it will be uncomfortable and the child will reject it. If there is distortion and the signal is not clear there is no reason to wear the technology.

Even if a child is hearing well at close and in quiet, are they hearing well enough in the classroom? If a child is not hearing in the classroom how will she learn? A possible reason for rejecting technology.

Children get clear messages from parents. If parents do not support the use of technology the child will understand and not want to use the technology. They also get messages from others around them. We know that children with disabilities can be bullied. If a child is refusing hearing aids one of the things we need to check is whether they are being bullied. We can just (and we must) ask. If a child has significantly delayed language she will have difficulty managing in the classroom. This may also be a reason for rejecting technology.


Language and/or academic delay

This one is significant. There are a lot of reasons why a child may have a significant language or learning delay. How to manage it varies. Catch-up is difficult. Intensive therapy is required to catch up. The rule is that a child needs one hour of therapy a day for each year of delay. If a child has a two year language delay, she will need two hours of speech-language-listening therapy/day to catch up. If literacy skills are 2 years delayed he will need two hours/day of literacy. I have worked with children who have had these kinds of significant delays. I have suggested, at IEP meetings, that the child receive this kind of intensive remediation. One school district told me they could not provide this kind of individual intensive therapy because the child would not be in the least restrictive environment. They obviously did not understand that when providing an appropriate education for a child we need to provide what the child needs, not just keep the child in a mainstream classroom.


Would sign language be a solution for a child who is either not wearing technology or is delayed in language or academics

This is a question that has come up more often then I would like. And my answer will likely get me a lot of hate mail. We need to find a way to improve a child’s language skills but why would we think that teaching the child a new language will help? Language is learned by exposure. If a child does not have sufficient exposure to sign language how will she learn it? If parents are not fluent in sign language the child will not receive language stimulation at home. If a child is in a mainstream classroom how will the child follow academic instruction? (Will an interpreter be enough?) How will the child socialize with classroom peers? Is the solution to move the child into a school for the deaf and teach the child sign language in that environment? If a child has significant delays, maybe. But we need to remember that communication will be limited to those at school. I am trying to learn Italian. I am not doing it well. If a child had to learn Italian from me she would have very limited skills. If a child had to learn sign language from a parent who was learning sign language at the same time, language stimulation would be limited at home. I am not saying that sign language is not something to consider, I am just saying that it is important to be realistic. There is no reason to believe that learning sign language will either be easy or will resolve learning issues.