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.