I recently consulted with a family which was concerned about the educational performance of their 9-year-old son with hearing loss. He was demonstrating significant language delays, which were resulting in significant learning problems, including reading delays. Everyone, including the faculty at the boy’s school, assumed that all his problems were due to hearing loss. As a result, they seemed to conclude that the problems were beyond their control and that there was nothing for them to do. They felt that for this child’s educational performance, “good enough” was all that could be expected.
But was this really true? It is important in cases like this to determine whether speech, language and learning disorders are, in fact, caused by hearing loss, or whether they are related, at least in part, to other issues. Determining the cause of an educational delay is critical to devising a management plan. In other words, we need to know what to fix.
First, test the technology
My first task in this case was to determine if the child I was evaluating was hearing well enough to learn by listening. He was late identified and had received cochlear implants at age 3 years. So we needed to start by testing hearing with technology to see how well the child could hear. The first thing we did was obtain thresholds with his cochlear implants. Thresholds were at 25 dBHL throughout the frequency range in each ear. He was able to accurately repeat all Ling sounds in each ear. He could also repeat nonsense syllables correctly, identifying all consonants and vowels. However, he could not accurately repeat sentences.
We know that for most hearing-impaired children, what they hear is what they say. For the most part, I find that speech production is a good indication of what a child is hearing. In fact, many years ago doing my work at the League for the Hard of Hearing, Dorothy Noto Lewis made us draw an audiogram based on talking to the child before we began testing. It was a wonderful skill to develop and has left me in good stead as a pediatric audiologist.
For this little guy, speech production is very poor; his speech is almost unintelligible, even to a clued listener. Sentence structure is poor, with missing articles and very short sentence length. So, what is causing this? If he can hear, why is he so delayed? What else is going on?
The next step was to evaluate all the child’s skills to help determine all contributing factors. I recommended a psycho-educational evaluation by a tester who has experience working with children who use cochlear implants and are educated in auditory-oral programs.
I recommended this person because it is important that the evaluator be able to distinguish behaviors and test responses that are related to hearing loss from those that are not. For example, if the room is noisy with auditory distractions and directions are given verbally, a child who does not hear the directions may not accurately respond to test questions. But the reason for the poor response is that the child did not get appropriate directions, not that he doesn’t know the answers to the questions.
My next recommendation was to obtain a speech-language-listening evaluation by an auditory verbal therapist or other speech-language pathologist who is knowledgeable about assessing listening and spoken language. Again, it is critical that the tester have the appropriate skills and be able to set up a test situation to maximize test results and to separate responses that are related to hearing from those that are not.
Oral motor evaluation
Because this child’s speech production was so poor, and because it did not appear that hearing was a factor in his speech production, an oral motor evaluation seemed like a good idea.
The parents asked if other evaluations should be considered. They were concerned that there might be some neurological issues that needed to be addressed to explain the poor performance and delays. From my contact with the boy, I do not think there are neurological issues, but there certainly is no reason not to get the additional evaluations. But before making any recommendations for additional evaluations, I want to see the results of the speech-language-listening evaluation, the psycho-educational evaluation, and the oral motor evaluation. After receiving those evaluations, I think we will have a better picture of how this child is performing, what his strengths and weaknesses are, and what we need to do to plan for his future.
When a child with hearing loss has poor speech perception, we should not simply accept that as the natural and inevitable result of the hearing loss. Kids who are well fitted with technology and have received appropriate therapy should have good speech production. If they don’t, there has to be a reason.
Always suspect technology first, then move on to other evaluations to get a full picture of the child. All testing should be performed by clinicians experienced with working with children with hearing loss who are educated in auditory-orally. Only with the right information can we plan appropriately for our children.