♦ Early Intervention and the Law

Three of every 1000 babies born in the United States each year have a profound hearing loss. Given this statistic, ˜33 infants are diagnosed daily with a hearing impairment. Another two or three of 1000 babies are born with mild to severe hearing losses (Johnson et al, 1993). The educational cost for not identifying children early is estimated at $420,000, with a lifetime cost of approximately $1 million per individual. From a cost-benefit perspective, the impact of early identification and early auditory access and language development cannot be overstated (Francis et al, 1999).

According to the Centers for Disease Control and Prevention, as of 2004, newborn hearing screening is mandated in 37 states. Early Detection and Hearing Intervention (EDHI) programs have the following stated goals:

1. Screening an infant before 1 month of age
   
2. Audiologic management, including the use of amplification, by 3 months of age for those children with a hearing loss
   
3. Entry into an early intervention program by 6 months of age

Early intervention programs have been in existence since 1986. Congress established the Program for Infants and Toddlers with Disabilities (Part C of IDEA), a federal grant program with the following functions:

1. Enhance the development of infants and toddlers with disabilities
   
2. Reduce educational costs by minimizing the need for special education through early intervention
   
3. Minimize the likelihood of institutionalization, and maximize independent living
   
4. Enhance the capacity of families to meet their child’s needs

An understanding of the implications of Part C of IDEA benefits professionals whose charge it is to guide and counsel families as they enter the early intervention system. As previously stated, cochlear implants are approved for children as young as 1 year of age and younger if appropriate. If we are giving infants auditory access to spoken language with cochlear implants during this critical period for learning, a primary goal of early intervention is to maximize the auditory potential for the development of competent oral communication. With earlier implant there is the potential for the stages of auditory, speech, and oral language development of the hearing impaired infant to closely approximate that of his typically hearing peer, given appropriate interventions, and family support.

Of greatest significance is wording in the law that recognizes the family members’ role as decision makers regarding how their infant or toddler will communicate. Given that the majority of hearing impaired children are born into families whose parents are typically hearing, recognition of the viability of spoken language as a communication option for deaf or hard-of-hearing infants warrants attention. With an early emphasis on spoken language development due to available hearing technology, the other immediate and obvious mandate of early intervention (i.e., reduce institutionalization) is the potential shift to community-based programs for greater numbers of deaf and hard-ofhearing children as they age out of early intervention.

♦ Communication Therapy Options in the United States

Auditory-Verbal (Unisensory) Method

The emphasis is on audition as the primary means for learning to process spoken language. Principles of the approach (Pollack et al, 1997) include:

1. Early detection of hearing impairment, with an emphasis on newborn hearing screening
   
2. Appropriate medical and audiologic management to ensure that amplification or a cochlear implant allow for maximum access to spoken language
   
3. Parents and caregivers are viewed as the primary models for spoken language development, and remain as active participants throughout the child’s intervention and education.
   
4. Integrating audition into the personality of the child so that listening is viewed as meaningful and primary for learning and functioning in the mainstream of society
   
5. Auditory verbal development is grounded in one-on-one teaching that includes the therapist and parent caregiver. Hearing-impaired children are not grouped together for learning.
   
6. Development of an auditory feedback loop so that the child monitors not only his own speech but also the speech of others
   
7. Communication follows typical developmental patterns to promote listening, speech, language, and cognition in natural communicative exchanges.
   
8. Ongoing assessment of the child’s development; auditory verbal therapy is diagnostic in nature and supports ongoing analysis of the child’s progress
   
9. Integration into regular education as much as possible to allow for typical speech, language, and auditory models, as well as a typical curriculum that supports age-appropriate academic and social learning

Auditory-Oral Method

The emphasis is on spoken language development through the use of appropriate-fit amplification or a cochlear implant, and individual and small group learning with hearing-impaired peers. Auditory oral programming varies in its defining characteristics, from advocacy for early mainstreaming using one-on-one teaching and small group instruction, to full-time programming with other hearing-impaired children. As a result of early diagnosis and cochlear implants, there is a growing emphasis on auditory-oral early intervention and preschool education to prepare the child for entry into regular education during the elementary years. The Alexander Graham Bell Association (1998) has published Components of a Quality Auditory Oral Program,which has a checklist with the specifics of an appropriate program using this approach for hearing-impaired children.

Cued-Speech Method

Cued Speech supports spoken language learning through eight visual cues that distinguish consonant phonemes, using four different placements near the mouth to distinguish vowels. These cues are used while speaking to make the ambiguous components of spoken language visual, particularly those that look similar on the lips such as [b], [p], and [m]. Spoken language is the goal with integration into mainstream education. Use of amplification or a cochlear implant is supported by available visual cues and speech reading. The parents must use the cuing system whenever they communicate with the child, and work toward proficiency in the use of cues while speaking.

Total-Communication Method

Total communication uses a combination of sign language in English word order, speech, and audition to develop language. Speech, speech reading, sign language, natural gestures, print, and hearing are used in this approach. Children are grouped according to their age and diagnosis as they enter the preschool years. This approach believes that children will respond to the sensory modality (i.e., hearing, vision, touch), which facilitates their learning at any given time, and parents learn signing to provide consistent modeling of this multisensory approach at home. Signing and speaking (i.e., simultaneous communication) is the general expectation within a total communication approach; however, that can vary from program to program.

American Sign Language/English as a Second Language (ASL/ESL): Bilingual/Bicultural Method

This approach uses manual language that is distinctly different from spoken language in grammar and syntax. It is the accepted language of the deaf community and is found generally in schools for the deaf in the United States. English is learned as a second language, using print and increased fluency in American Sign Language as a primary avenue to spoken word order and grammar. The emphasis is on a manually encoded language system that allows for early communication. Audition and spoken language are not emphasized when using American Sign Language. Access to appropriate language models fluent in the language of sign is critical. Parents of hearing-impaired children must be able to communicate in the chosen language. Not only is it important for the child to be immersed in the language and culture of the deaf, but it is equally or perhaps more critical that the family members immerse themselves in American Sign Language.

♦ Cochlear Implant Research Supporting Auditory-Based Learning

In a study completed by Svirsky et al (2000), 70 children with cochlear implants were assessed ˜4 months before receiving their cochlear implants, and 6, 12, 18, 24, and 30 months after implantation. The purpose of the study was to determine the English language abilities of children with cochlear implants. Their scores were compared with the language age they might obtain as a function of chronological age, residual hearing, and communication mode. Children who received cochlear implants had a mean rate of language development similar to that of children with normal hearing, and greater than that of deaf children who were not implanted. There was a relationship between better speech perception scores and more normal oral language development. Children who were oral communicators versus children using total communication demonstrated this effect to a greater degree. Overall, children with high speech perception were developing oral language skills based on the auditory input of the cochlear implant. In a study by Kirk et al (2002), the oral communication early-implanted children demonstrated spoken word recognition improving at a faster rate, and the oral communication children made more rapid gains in communication abilities than did the children who used total communication. Finally, in a study completed by Osberger et al (2002), age at implantation, educational setting, and communication mode influenced speech perception performance with a cochlear implant. Children from oral educational backgrounds demonstrated more benefit than did those from total communication programs. Individual variance in performance remains regardless of the educational option; however, generally speaking, as a group, children in auditory-oral programs are demonstrating better auditory, speech, and language skills, which translate to greater academic performance and the ability to learn in regular education settings.

♦ Auditory Development and the Implanted Child

Regardless of the communication and educational option, the stages of listening as established by Erber (1982) from detection to comprehension are the foundation for developing the ability to use audition meaningfully, and learning spoken language. For children who are not in programs where spoken language is the only expectation, the practitioner must be vigilant in ensuring appropriate integration of this developmental process. The typical expectation is at least a year’s progress in a year’s time relative to auditory, speech, and language development. For those children who are not meeting that minimal expectation, assessment must begin to determine the appropriateness of the intervention and the educational setting, as well as determine if there are other possible contributing influences, such as level of family involvement and other learning issues.

Hierarchy of Listening Skills from Detection to Comprehension (Adapted from Erber, 1982)

Detection

The ability to respond to the presence or absence of sound: the child learns to respond to sound, pay attention to sound, and not respond when there is no sound.

• Selective attention to sound
  
• Searches for and localizes sound
  
• Conditioned response to sound
  
• Spontaneous awareness of sound

Discrimination

The ability to perceive similarities and differences between two or more speech stimuli: the child learns to attend to differences among sounds, or to respond differently to different sounds.

Identification

The ability to label by repeating, pointing to, or writing the speech stimulus heard.

Suprasegmentals

• Prosodic features of speech (duration, pitch, loudness, rhythm, stress, intonation)
  
• Recognition of a man’s, a woman’s, and a child’s voice
  
• Learning to Listen Sounds

Segmentals

• Learning to Listen Sounds
  
• Words varying in number of syllables
  
• One-syllable words varying in vowel and consonant content
  
• Stereotypic messages (familiar expressions and directions)
  
• Words in which the consonants are identical and the vowels differ
  
• Words in which the vowels are identical and the consonants differ in manner and place of articulation, and in voicing
  
• Words in which the vowels are identical and the consonants differ only in manner of articulation
  
• Words in which the vowels are identical and the consonants differ only in voicing

Comprehension

The ability to understand the meaning of speech by answering questions, following instruction, paraphrasing, or participating in conversation. The child’s responses must be qualitatively different from the stimuli presented.

• Familiar expressions
  
• Follow single directions
  
• Follow classroom directions
  
• Sequence 2, 3, and 4 critical elements
  
• Sequence 5 directions
  
• Sequence multielement directions

Auditory/Cognitive Skills in Structured Listening Set

• Sequence series of multielement directions
  
• Identify based on related descriptors
  
• Sequence 3, 4, and 5 events
  
• Recall 5 details of an event, story, or lesson
  
• Understand main idea of a lesson or complex story

Auditory/Cognitive Skills in Conversation

• Answer questions requiring comprehension of the main idea of a short conversation
  
• Paraphrase remarks of another
  
• Offer spontaneous remarks

Auditory learning encompasses both receptive and expressive spoken language development, as well as speech perception and production. No skill is taught in isolation, hence listening, speech, and spoken language develop simultaneously. Learning is viewed from a typical developmental perspective in the early years. Progression should parallel that of the implanted child’s same-age hearing peers, realizing that the older the age of the implanted child with limited oral experience, the more systematic and intensive the approach to speech and language learning.

♦ Education for Deaf/Hard-of-Hearing Students in the United States

Transition from Early Intervention to School (Preschool and Older)

Families are enrolled in early intervention programs under Part C of IDEA transition to Part B, Children with Disabilities (3 to 21 years) at or around age 3. The focus shifts from family-centered to child-centered programming. Local education agencies assume responsibility under the state Department of Education. An individual education plan (IEP) is developed based on multidisciplinary assessment, and is influenced by the stated communication option. This legal document is critical for establishing not only the appropriate placement but also the approach. Hearing-impaired preschoolers are placed in a continuum of educational settings, from typical nursery schools alongside their same-age hearing peers to self-contained groupings as part of a program for hearing-impaired children, some with the option for inclusion with typically hearing children or part-time placement in regular educational settings. Another alternative is placement in noncategorical groupings with children with various diagnoses. For the child with additional handicapping conditions, placement in a program that specializes in other diagnoses may be considered. Children who are not placed in specialized programs for hearing-impaired children generally require support services from a teacher of the deaf and speech pathologist familiar with cochlear implants.

Determining Placement and Services

Critical to placement decisions and the development of either the individual family service plan (IFSP) in early intervention or the individual education plan (IEP) after age 3 is assessment that reflects an understanding of cochlear implants and their impact on speech perception, production, and language development. These assessments define how effectively the child is using audition for learning. As a result of these assessments, recommendations are made for appropriate acoustic learning environments that allow for auditory access to the curriculum, as well as an ongoing focus on auditory, speech, and spoken language development. They serve as the guide in developing goals and objectives for the child in his new educational program, as well as providing baseline information about the present level of performance to gauge the rate of progress. Rate of progress is especially important as we look at children who will be or are educated alongside their same-age typically hearing peers because not all children enter the mainstream with the same listening and linguistic abilities as their hearing peers. The child’s ability to close that gap with appropriate services, as well as the depth of that gap, is invaluable information.

Clearly, assessment must be completed by professionals not only familiar with the hearing-impaired population and strategies to elicit the desired response, but also familiar with auditory learning and cochlear implants. Interpretation of test results should include knowledge of other children with similar pre-and postimplant histories. Tests normed on normal-hearing children are an integral part of the assessment battery. Because the cochlear implant is an auditory prosthesis, with spoken language being one of the expected outcomes, test measurements must be compared with those of normal-hearing children in addition to those of implanted peers. With the swing toward educational placement on a continuum toward mainstreaming, standardized tests normed on hearing children provide the educational team with comparative data.

Speech and language assessments are only a part of a battery of tests administered that assist in determining appropriate placement for the student with a cochlear implant. Other assessments include, but are not limited to, audiology, psychoeducational, and a functional look (i.e., classroom observation) at the student by a teacher of the deaf or other qualified professional in the learning environment. Functional evaluations provide additional information about auditory, speech, and language in the environment in which the student is learning, and how those skills are impacting on academic and social development.

Classroom observation provides information about how the child is integrating auditory learning in his everyday learning activities as compared with test results. That information assists the classroom teacher by providing strategies to teach the implanted child, as well as promoting an understanding of why the child responds differently in various auditory learning situations.

Continuum of Auditory Skill Development

Ying E. (1990). Speech and language assessment: communication evaluation. In: Ross M, ed. Hearing-Impaired Children in the Mainstream. Parkton, Maryland: York Press; 45–60. Used with permission.

Questions to answer when observing a child:

• 
  

  When does the child use audition to receive information?

  
  

  Pair auditory cues with visual cues? How dependent is the child on visual cues?

  
  
• What is the impact of distance and noise on attention and listening?
  
• Is the child’s response to verbal requests and instruction appropriate? Is there only a nonverbal response required, or a verbal?
  
• Does the student have the ability to use a range of auditory skills in the classroom, from use of suprasegmental information to segmentals?
  
• Can the child listen to new information without contextual supports? How much contextual support is needed?

Information about how a child listens in controlled environments, such as one-on-one teaching, is not sufficient to develop individual educational plans. Ultimately, the goal for a child with a cochlear implant is to compare the results on standardized measures with auditory, speech, and language function in the environment in which the implanted child is learning. Because we know that the acoustic signal degrades as distance and noise increase, and because linguistic demands increase, the natural learning environment of the home and classroom offer challenges to auditory learning that cannot be assessed solely in controlled situations.

The course of the child’s learning experience in school changes significantly throughout the day: listening during seated instruction is uniquely different from participating in small group discussion that is rapid-fire in pace. There are times during the day when language is familiar, such as directions or review of previous material. Unfamiliar language, such as the language of math, may require different strategies for access. In addition to providing teaching strategies to maximize listening and speaking, classroom observation also can lead to a discussion about alternative placements if the child is not appropriately challenged, or lead to changes in the written goals and objectives to maximize auditory learning.

Classroom observations usually consist of discussion of the acoustic environment, teacher style, peer interaction, the implanted child’s skills, and the support team (Talbot, 2000). Considerations for auditory learning on an IEP generally start with adaptations to the acoustic environment. Classrooms are notoriously noisy environments for any child to listen and learn. For a child with a cochlear implant, a room that has not been managed acoustically poses an obstacle to access, a keyword in disability law. In 1957, J. E. J. John addressed the issue of noisy classrooms by stating the following: “One of the main tasks of those who are responsible for the education of most deaf children is to help them to get maximum benefit from the use of hearing aids, and this task does not end when a child has been given an aid and switched it on. … It is a sad fact that in a great number of schools little or nothing is done about room acoustics; in such conditions, hearing aids cannot be used efficiently” (Crandall and Smaldino, 2001).

Substitute cochlear implant for hearing aid in the above quote. Noise in a classroom that has not been acoustically treated minimizes the implanted child’s ability to be an active learner. Acoustic treatments for a classroom could include acoustic tiling, carpeting, and soft porous materials for the walls. The most effective management, however, is the use of an frequency modulated (FM) system, either sound field or personal. FM systems increase the intensity of the speaker’s voice in the child’s ear in response to noise, distance, and issues of reverberation in a classroom. Bilateral implantation is also being seriously considered to address the issue of noise and localization, two key listening issues in a classroom.

Determination of the appropriateness of an FM system is based on assessment by an audiologist. There is a growing demand for educational audiologists to be included in the implanted child’s IEP given the increased numbers of children in regular education. The Educational Audiology Association (1994) has published Minimum Competencies for Educational Audiologists, and extended that to include a description of the educational audiologist working with implanted students. Presently the responsibility for monitoring cochlear implants and assistive listening devices in regular education falls to the teacher of the deaf or other related service providers such as a speech pathologist, although schools for the deaf and larger public and private programs established for hearing-impaired children generally have the advantage of there being an educational audiologist on staff.

Beyond academic performance, one of the key components of a functional observation is the implanted child’s level of peer interactions. Social learning plays a critical role in the communication, as well as social emotional development of the child. The quality of the implanted child’s interactions with his peers, as well as a fellow student’s ability to provide appropriate auditory, speech, and spoken language models, influences questions of placement and the extent of intervention necessary to facilitate that interaction.

♦ The Relationship Between the Implant Center and the School

It is important to remember that early intervention programs and school districts may have limited or no experience with a hearing-impaired child, particularly a child with a cochlear implant. When a child is placed in an early intervention or educational program, it is imperative that the cochlear implant team has the personnel to respond to not only the needs of the child but also the needs of the school responsible for implementing the goals and objectives of the IEP. Members of the cochlear implant team can act as a resource, attend planning meetings, offer in-service training, and advocate for appropriate programming, services, and assistive listening devices for the implanted child. Regardless of the expertise of the educational program, ongoing communication between the school and implant center is critical, particularly relative to questions about device programming, cochlear implant equipment, and use of FM systems, or consultation regarding the child’s progress in auditory, speech, and language development, academic standing, additional teaching strategies to employ, or questions of additional learning issues.

Implant centers also play a critical role in assisting programs to bridge children from visual learning to auditory-based learning. Generally, children who are in total communication programs do not have the same expectation to use audition throughout the course of the day if a visual representation of language is consistently available. The challenge when looking at educational placement is to rethink opportunities for auditory learning for those implanted children. The goal is to move the child along the continuum of auditory, speech and language development while supporting his academic learning visually. This is particularly true for those children who are implanted later, and have an established visual communication system. At the start, this could include using detection of sound to expect the student to be alert to his name, when set to listen, or the use of suprasegmental contours for vocabulary learning. Auditory learning must be integrated, consistently and systematically, into the academic and social curriculum.

For the later-implanted student or adult who has learned visually, teaching strategies employed must recognize the listener’s interest level. Listening to associated sounds is not a meaningful exercise for a teenager; listening to music may be more motivating to develop the ability to listen and possibly recognize familiar songs through audition. Also practice with conversation using rehearsed scripts of familiar routines to the implant user, as well as tracking, which requires verbatim repetition of what was heard, are useful transition exercises. Both an analytic and synthetic approach is of value, combining listening to sounds of speech individually, for example, with listening to those same sounds in running speech. The key is to start at the implanted student’s auditory and motivational level, bridging him with known visual cues such as speech reading to an auditory emphasis.

Another category of implanted student is the child with multiple handicaps. Given the myriad needs of these children, teaming with educational programs plays an important role in integrating auditory skills with the global goals of the child. It is estimated that 40% of children with the diagnosis of deafness have other learning issues (Luterman, 2004). Those additional learning issues could include learning disabilities, mild to profound cognitive issues, attention deficit disorders, and developmental spectrum disorders, such as Asperger’s syndrome or pervasive developmental disorder (PDD), or children with global developmental challenges, such as a diagnosis of CHARGE syndrome (coloboma of the eye, heart anomaly, atresia choanae, retardation, and genital and ear anomalies).

Obviously, learning to use audition is influenced by other handicapping conditions impacting on the hearing-impaired child. The decision regarding placement and communication intervention strategies requires input from a multidisciplinary team. In addition, function must be seriously considered for generalized learning. Using audition meaningfully may require many more opportunities for experiential learning, and a longer time frame for integration of those skills. Placement often cannot be solely based on the child’s hearing loss given the need for professionals with experience in such fields as oral motor development, special education, and adaptive physical and occupational therapy.

The parameters that define educational placement and services are as individual as the child. Deaf children are more variable as a population than hearing children. When we apply a common label such as deafness to children, there is an implicit invitation to regard them as somehow more alike than is the norm (Wood et al, 1986). Placement and the process of learning are never static but rather are dependent on the progress of the student’s auditory, speech, and language abilities, in addition to considerations of other variables, such as additional disabilities. Decisions about communication approaches and educational placement must also consider the family’s preferred option. Any placement and subsequent development of educational goals and objectives must address the acoustic environment, the ability of the program and service providers to maximize listening and speaking (including but not limited to the teacher of the deaf, speech pathologist, and educational audiologist), the availability of appropriate peer models for oral communication, the integration of the family as key members of the team, annual communication evaluations to assess response to the strategies of intervention and educational programming, and coordination with the implant center to assist in developing appropriate MAPs (a ‘listening program’ stored in the memory of the speech processor) for the implanted child, as well as the implant team functioning as a resource regarding the overall educational management of the implanted child.

A cochlear implant is an auditory prosthesis and with time will become increasingly more sophisticated. Yet to know the impact of earlier implantation on the auditory processes of the brain, such as auditory memory and sequencing. With increasingly sophisticated technology and programming strategies, ongoing medical research, and greater collaboration across disciplines to avoid a myopic view of the child, we may see changes in future outcome studies relative to performance.

Deaf education, one could reasonably expect, accompanied by educational law and the impact of identifying hearing loss in infants, may also continue to make a dramatic shift from a self-contained model as more and more implanted children enter public mainstream education. There is no argument that cochlear implants have made a difference in the auditory, speech, and spoken language outcome of hearing-impaired children and adults. Research now is moving toward questions of higher order processing as a result of oral language development. Language-related performance in such areas as reading and writing is of great interest as is the influence of implants on the social and emotional development of implanted children who are in increasing numbers learning alongside their typically hearing peers.

For families of hearing-impaired children, ensuring equal access to information about choices in communication and educational options, as well as implant technology, falls to the practitioners in the field of deaf education and related fields. The mandate is to be prepared professionally to respond to the expectations presented as technology opens the door for greater auditory access, and the potential for spoken language development in addition to the child’s own innate abilities. At present, educational placement in the United States, beginning in early intervention, remains as varied as the population of implanted children. The range of professional training and experience relative to auditory learning and spoken language development is equally variable.

References

Alexander Graham Bell Association for the Deaf and Hard of Hearing. (1998). Components of a Quality Auditory Oral Program (booklet). Washington, D.C.: Alexander Graham Bell Association for the Deaf