Hello, my name is Ellen Thomas and this lecture is about the effects of hearing loss on listening and spoken language development. We'll start with some acronyms that are commonly seen in the field: HL is used as an abbreviation for hearing loss. DHH is often used to refer to deaf or hard of hearing. LSL refers to listening and spoken language. HA is the common abbreviation for hearing aid. CI is the common abbreviation for cochlear implant, and Baha refers to bone anchored hearing technology. It's also helpful to understand some terms that are used in the field of listening and language. Receptive language is the term used for the language that you understand. Expressive language is the term for what language you use. If you think about the language that you might read in a text and understand, probably differs considerably for how you would form a sentence or what words you might choose to use when you're talking, and this is the difference between receptive and expressive language. You can also think of it in terms of learning a foreign language where you frequently understand much more than you're able to express. This super segmentals of the language are the melody or the music of the language. They are the duration, the intensity, and the pitch changes that occur in the language. You can recognize when the super segmentals of a language are off when you listen to somebody who might be speaking your native language as a second language and you recognize that they have a good understanding of the grammar, they are producing the sounds of the language well, but it just doesn't sound right, and this makes them difficult to understand. When the super segmentals of the language are not correct, it impedes intelligibility. Articulation is the way in which we produce each sound of the language. In English, the sound of the th is often a sound that causes non-native speakers some problems because produce in their native language. When we talk about the effects of hearing loss on language development, we have to talk about the critical window or the developmental period for speech and language which is birth to five years. This is the time when the neuroplasticity is greatest and when the brain is wired to acquire language. We're all born with the potential to learn any of the world's languages, but it's the based on what we hear in our environment that drives us to select which phonemes we're going to attend to and develop language that we acquire. Hearing loss often affects educational outcomes and social interaction. If we look at the educational outcomes, we know that hearing loss creates delays in speech and language development, which in turn leads to difficulties with learning in school. If a child does not have the auditory memory needed to retain a direction like, open your book to page 52 and do problems one through five, they're going to struggle in school. If they don't have the vocabulary basis to add to at a particular stage in their education, they're going to be left missing some key concepts. So if a child does not understand the parts of a plant or how plants grow at all, then understanding photosynthesis and adding that term to their vocabulary is going to be a very difficult proposition. Hearing loss also impedes literacy, not only from a vocabulary standpoint, which it does, but also because literacy is grounded in phonics and listening to speech at a single sound level. If that is missed or not acquired easily, we're going to see the effects in a poor literacy outcome. Now, social interaction is also often delayed. Somebody who doesn't overhear easily and pick up on social cues will often have delays in the concept of theory of mind or the ability to recognize perspectives other than your own. The child with a hearing loss might become more egocentric than their siblings and not recognize that somebody is not sharing all the knowledge they have and miss some subtle cues or feelings expressed by another. This ends up impacting self-esteem. When a child has been delayed in either education or in the Theory of Mind, they begin to recognize it, at least to some extent, and this will weaken self-esteem. It also will have a negative impact on social relationships. Hearing loss is an invisible problem. Children who don't hear instructions or mishear them are often perceived to be behavior problems, when in fact the root problem is a hearing problem. Things teachers say that often indicate the hearing loss is interfering are things like," He doesn't pay attention. She's always looking around and can't focus. She never listens to me. He always ignores me." These are things that teachers perceive when a child in fact is not hearing well. A child who's looking around and can't seem to focus may be looking for visual cues as to what's going on to keep them on track. One of the most common problems experienced by young children is the buildup of middle ear fluid. When middle ear fluid is present, it can create a mild up to a moderate hearing loss that muffles the signal getting to the brain. Even a temporary problem, and middle ear fluid should be a temporary problem, can result in poor articulation and intelligibility in early childhood and needs to be addressed in order to have that child correct their speech production when they're hearing returns to normal. Now in the case of a child with a permanent hearing loss in addition to a transient one caused by fluid, you end up in double trouble. A child with a hearing loss cannot afford to wait several weeks for fluid to resolve. The cost to their speech and language development is simply too great. While conventional wisdom from a medical standpoint may be that the fluid will resolve and it is better to allow that to occur naturally, for this child who has an additional hearing loss where time is critical to achieving age appropriate speech and language, we want to be sure that we act aggressively. When fluid is present, the use of hearing aids with earmolds may be painful, and the hearing aids are no longer as effective because they're not programmed to meet that degree of hearing loss. The hearing loss has become more severe simply by the presence of the fluid. Paul Meyer is quoted as having said, "Communication, the human connection, is the key to personal and career success." This is an important idea to keep in mind when we're talking about children with hearing loss. We want to intervene early so that they achieve their potential in terms of education and career success, and social interaction. We don't want to let hearing loss derail this so that we end up with an individual who's not able to contribute at their full potential. You may have heard people refer to "deaf speech". Deaf speech is usually accompanied by a severe to profound hearing loss in an individual that doesn't have adequate access to sound using hearing technology or maybe is not using hearing technology. The effect is on the resonance of the speech. So there's generally what's referred to as a cul-de-sac resonance. That means that everything is centered further back in the oral cavity so that it sounds like this. There's also usually poor volume or pitch control. The individual is unable to monitor their own speech through hearing, so there's no auditory feedback loop to help with these problems. There's also typically some disordered articulation where the sounds are distorted or maybe even omitted, and the hearing loss is very much identifiable by the characteristics of the individual speech. This leads us to looking at the terms 'deaf' or 'Deaf'. When there's a child with a severe-to-profound hearing loss that can't hear themselves speaking unless they're using hearing technology or maybe the hearing technology is not able to provide them with adequate access, they often use a sign language as their main mode of communication. When "Deaf" is capitalized, it indicates that the individual is a user of a sign language and a member of the Deaf Community which is accompanied by its own culture and usually very close-knit with social interactions among the members, taking a certain precedence in that person's life. This happens for the reason that Rollo May expresses that communication leads to community. We see this too when speakers of a non-native language are living somewhere where their language is not the dominant one and yet the group of people that speak the same language tend to cluster together. Again, this is because communication leads to community, and language extends off into the culture and the type of beliefs that a group may have. So communication is an important concept and an important factor to consider when you're talking about a child born with a congenital severe to profound hearing loss. Today, almost all children who are deaf or hard of hearing have the potential to learn, to listen, and talk. This is historically certainly not been true, but in today's world, it is. Two things changed the landscape of potential for children born with significant hearing loss. One is earlier identification with the advent of newborn hearing screenings in the first few days of life. In the US, this is managed under EHDI or Early Hearing Detection and Intervention, allows us to know very soon whether a child has a significant hearing loss so that we can begin to understand and provide intervention very quickly in that critical window for speech and language acquisition of 0-5 years. We also have seen the advent of far better technology. Cochlear implants have opened the door for many individuals with profound hearing loss to have access to the sound needed to develop listening and spoken language. Our hearing aids are also better and bone-anchored hearing technology helps those with conductive losses achieve earlier and better access to sound. All of this allows for the possibility that children with most any degree of hearing loss will be able to learn to listen and talk if that's the chosen goal. However, not all children are going to have that potential, and it's important to recognize the factors that take away the potential for listening and talking. One is the absence of an eighth cranial nerve or the auditory nerve. If the ear, that doorway to the brain is unable to provide access to the brain, then listening and spoken language is not going to be a viable option. Sometimes, cochlear anatomy is abnormal enough that a cochlear implant is not able to provide good access to sound. The last two which tie to what has provided the potential look at what can take away the potential. One is if technology is not used as recommended, it doesn't work. Wearing a hearing aid or a cochlear implant a couple of hours a day is not going to result in the development of good listening and talking. Because there is a critical window for the development of language, a recognition of a congenital hearing loss at an older age, then fitting amplification and looking to develop speech and language is not going to be highly successful, it's going to be very limited. So identifying that an individual has a hearing loss late is also going to take away this potential for listening and talking. Now, let's look at what it takes to tap the potential so that a child who is born with a severe to profound hearing loss can develop listening and spoken language at a level that is commensurate with their same age peers who have normal hearing. What it takes is early identification ideally right after birth, appropriate technology for the hearing loss, fit well, and full-time use of that technology. Dr. Teresa Caraway has coined the term for parents "10 to Win". So the goal is to use the technology at least 10 hours a day. This is what it takes for a child who has a congenital hearing loss to be able to catch up to the language level of their peers with normal hearing, as with all of child raising and parental involvement is a key component to success. Intervention, despite the wonders of the technology and early identification, we know that our outcomes are still best when there is the involvement of a professional that's able to guide the child and family to habilitate the development of speech and language. Our preference are the skilled professional that holds the Certified Auditory-Verbal Therapist or Auditory-Verbal Educator designation, but this is not always available and certainly, we want to use the professional who is best able to help the family achieve their outcome that they're looking for. There's some common effects of congenital deafness on listening and spoken language. In babies that are under 12 months of age and aren't getting adequate access to sound even if they may be fit with hairy days, if the access isn't good enough, we often see language development stall at a 0-3 month level. They simply don't have the hearing it takes to progress farther. You can also see the babies in this situation are visually vigilant in a way that children with typical hearing are not. Another indicator can be that these infants often vocalize both on in and exhalation for an extended period of time. Babies with typical hearing will often play with that but it doesn't endure. Babies with a profound hearing loss often vocalize for a long period of time both on in and exhalation. This video shows a five-month old with a severe to profound hearing loss who is using hearing aids and they're providing some access to sound, but she's still does not have good access to the full speech spectrum of sound and you'll hear that she vocalizes on both in and exhalation. Now, we'll look at a video of the same child a year later and you can hear the change in the vocal quality and of the babbling with four months of cochlear implant use. This is very normal sounding babble. What she's doing there, that is exactly what you have here from baby that does not have a hearing loss. Hearing loss also has an impact on receptive language. Listening requires effort, and when it becomes very effortful, the listener usually keys in on key words, stressed words so that the message received becomes "Get shoe" versus "Go get your shoes", or "Mommy want ball" versus "Mommy wants the ball." This results in the dropping of unstressed function words like articles "the", prepositions, and also word endings are missed. So plural endings, endings designating tense. So an ed ending are often missed or misheard. This then, in turn, will affect expressive language. One of the most important things to consider when you're talking to a child who has hearing loss is that you talk how you hear. So there's a lot of information given in how a child is hearing based on what they're doing in their own speech. The output tells you a lot about the input. Often, speech maybe telegraphic, word endings may be dropped, function words might be dropped, there may be slurring or garbled speech because of an unclear signal. This video shows a brother and sister where the sister has a profound bilateral hearing loss and has bilateral cochlear implants. She uses ASL at school but speaks English and some Spanish at home. These siblings have a very close relationship, and the brother can often serve as an interpreter for the sister when communication goes awry. We want however to help the sister acquire those things that can be hard to master in the language so that she's able to speak competently for herself. Tell me how old are you? Eight. Fernando, how old are you? six. When is your birthday? It's soon you think? [inaudible] I can. What's your birthday? On 12 days. In 12 days? Okay. Let me count. No. You said in 12 days, so that would be 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12. [inaudible] On July 29th? Yeah. And then you will be? Seven. I can carry [inaudible] today because [inaudible] and I try and stand up. She was trying to carry me and I'm on her back. What? Yeah. I'm too heavy. Yeah. We almost fell. I think so. He's not a baby. He's too heavy. No. He's not a baby. I told you. He not a baby because he grow up. Yeah. He grow up. that's right. Hearing loss also has a big impact on vocabulary because we learn most of our vocabulary by overhearing it. It's not taught directly to us, but we overhear it being used in one context or another. Because a hearing loss makes it more difficult to overhear, the acquisition of new words is slower. Without intervention, children with hearing loss frequently become very delayed in their vocabulary. This, in turn, can result in delays in literacy. There's also often difficulty with understanding that the same word can have multiple meanings. So often, intervention needs to work on words that have multiple meanings so that this becomes a concept that's understood and can be recognized when a new word is introduced. These delays become cumulative and limit academic achievement, and this is what makes early interventions so critical to the success and the outcomes of a child with a hearing loss. So although, six months or a year doesn't seem like a lot of time to an adult or to a parent who may be grieving the fact that their child has a hearing loss, it is valuable precious time that can change potentially the outcome of an individual. So this concludes our lecture on the effects of hearing loss on speech and language. Thanks for watching. We hope you'll watch some of our other videos.