**6.1 Amplification and listening environment**

122 Hearing Loss

agents that best understand child's intentions and thus can best provide the scaffolding that they needed during the early development (Brown & Nott, 2005; Bloom, 1993; Bruner,1983;

Studies in the past conducted with children older than 18 months of age showed that parents of children who have hearing loss undergo controlling, discouraging and negative interactions with their children which provide a less facilitative environment for language acquisition and for social and cognitive development (Schlesinger & Meadow, 1972). Some studies argued that linguistic competence of the child would determine the parent's interaction with the child. If the child's language level is behind their chronological age parental control, simplicity and directivenes in language are increased and becomes different than the language used while addressing normal hearing children at the same age. (Gregory, et. al., 1979). Even in the earliest stages, differences in interactive behaviour were reported. Meadow, et. al. (1981) indicated that deaf infants of three, five and eight months had more physical contact with their mothers than hearing infants, suggesting that mothers of deaf children exploit the tactile kinaesthetic channel for gaining and holding attention rather than well known child directed speech features such as shorter utterances. Hughes and Huntington (1986) reported distorted speech and phonologic/prosodic characteristics in some mothers' of deaf children. They were easily recognized by listening to audiotaped voices during their interaction with the child. It is argued that distorted speech and altered intonation make the speech even more difficult to understand since they effect the second formant information. These kind of interactive differences possibly had negative effects on

Early identification, amplification and intervention provide a chance to prevent deviances from normal interaction by providing auditory information to the child and supporting parents in their interactive skills immediately. Indeed it becomes possible to follow normal developmental patterns in language development without considerable delay and in most cases with no delay at all (Brown & Arehart, 2000; DesJardin, et.al., 2006; Moller, 2000; Hoberg-Arehart & Yoshinago-Itano, 1999; Houston, et.al., 2003; Robinshaw, 1995; Spencer, 2004; Wallace, et.al., 2000; White, 2006, Yoshinago-Itano & Apuzzo, 1998). Starting with the diagnosis of the hearing loss, parents should be encouraged to follow normal interaction

Daily activities such as feeding, cleaning, dressing and simple play routines provide excellent opportunities of language learning for babies younger than one year old. The repetitive nature of the daily routines consolidates the experience and the language that accompanies them. By talking about the things they do during these activities parents are most likely to provide meaningful language input to the child. Following the baby's gaze and responding to his/her vocalizations help parents to regulate turn taking and to

The professional should guide and coach the parents in such a way that they come to realize that listening and speaking are a way of life for development of language in babies with a hearing loss. The parents' awareness should be heightened on how much they are already doing naturally and to encourage them to do more of it. The idea is not to intrude into the child's self-absorbed exploratory play in order to engage him/her in talk every waking

Wilson, 1998; Mahoney & Wiggers, 2007; Mahoney, 2009).

language development of children with hearing loss in later ages.

understand his/her intentions. (Brown & Nott, 2005; Clark, 2007).

patterns during their daily life.

**5. Effects of a hearing loss in interaction** 

Hearing aids and cochlear implants properly adjusted are the core of auditory oral or verbal intervention programmes. It is possible to fit and adjust internal settings of the hearing aids or cochlear implants with objective techniques in today's technology. Digital hearing aids are so flexible that they can be easily set for very young ones and it is possible to programme cochlear implants using NRT (Hughes, et.al., 2000), eSRT (Kosaner, et. al., 2009) and cortical responses (Sharma, et. al., 2005) even for babies younger than one year old. Combined with careful behavioural observations at home and clinics it does not take long to achieve optimum adjustment of the hearing aids or cochlear implants. However, the main issue is the effective use of hearing devices after fitting (Brown & Nott, 2005; Clark, 2007; Cole & Flexer, 2007).

Particular attention should be paid to train parents in effective use of hearing aids/cochlear implants during all waking hours of the baby. The parents must accept their responsibility in constant and efficient use of hearing aids or cochlear implants since babies spend all of their time with the family. When parents purchase the hearing aids it is the professional's role to help and supervise parents until they feel comfortable enough to check and fit the devices onto the baby properly (Clark, 2007). Guiding parents in hearing aid use and solving the problems related to hearing aids improves parents confidence in dealing with the devices and motivates them in efficient use. They should be advised about the frequently checking the external controls of the devices and batteries during the day because babies and young children are not capable of signalling the problems of the incoming sound. Adults must detect and solve the problems in the hearing aids/cochlear implants to provide constant flow of the auditory information. It is possible to lock external control settings of the digital hearing aids/cochlear implants during programming of the device which provides confidence about the exact settings in daily use. Batteries should be checked if they keep supplying the power during the day.

Feedback is the major problem while using hearing aids with the very young ones since the pinna is too small and soft to support the weight of the hearing aid and the neck support at this age is weak. It is possible to prevent feedback problem by using soft ear moulds and specially designed long spiral shaped tubing which allows attaching the hearing aids over shoulders until the baby start to hold his/her neck securely and sit up with no support.

Parents also need to know that hearing aids/cochlear implants does not restore the hearing to the normal. It is necessary to inform parents on deteriorative effect of the background noise over speech sounds and the negative effect of the microphone distance on speech perception. It is easier to accomplish optimum microphone distance with babies during their first year in life since we talk to them literally in an "ear shot" while holding them in arms or in their cribs. It is also advised to use a FM system in noisy conditions.

Parents should also be warned to be sensitive about voice clashes. It occurs while more than one person is talking at the same time during their interaction with the baby. As an

Early Intervention with Children

focusing on the hearing loss.

**7. Role of the professional** 

Who Have a Hearing Loss: Role of the Professional and Parent Participation 125

must understand to recognize opportunities to facilitate language learning during the daily activities through following child's interest and being sensitive to communicative intentions of the child. Once parents understand to use language facilitating strategies in daily routines, they become active partners in creating these opportunities (Brown & Nott, 2005;

Some time during the session must be spent in discussing the things parents have done with the child since the last time they have been to the session. Also parents must be asked if they want to discuss any thing related to the child's development or progress. The parents should feel free to share their concerns or questions with the professional as well as positive signs of the progress. The professional should be able to refer parents to related professionals if their concerns are beyond the scope of the intervention process such as suspicion of a second handicap, neurological problems or necessity of psychiatric evaluation

Each session should include a musical activity or a listening game to improve listening skills of the child. Parents often need help to create suitable activities during the first few sessions. Therefore it is advised to dedicate time for age appropriate and enjoyable listening activities in each session. Parents must understand that these activities improve listening skills and are also enjoyable. Singing lullabies, rhymes and simple repetitive songs are highly recommended to widen the child's listening experience and to develop a sense of rhythm (Clark, 2007; Cole & Flexer, 2007; Estabrooks, 2007). Naturally occurring sounds at home such as door bell, telephone ring, and sounds from outside can also be used to develop listening skills. Parents are advised to listen to the sounds at home themselves first,

At the end of the session it is better to discuss language enabling activities and areas of language that might be focused at home. Caution should be taken that parents provide a language enhancing environment to the child. It must be remembered that language is a complex, specialized skill that develops in a child spontaneously and it is not something that

Sometimes it is better for the parents to see the professional interacting and talking with their child in a natural way. Professional's attitude towards the child encourages parent to expect age appropriate development. It is highly motivating especially after the diagnosis for some parents to see someone treating their child in a normal way who is not solely

Advice given in the early years to the parents of children who have a hearing loss has long lasting effects on the children's development and future lives. The professionals who first come into contact with families seeking advice on how best to manage a young child who has a hearing loss bear tremendous responsibility for their futures (Clark, 2007). Their role is complex and challenging. It is different from other professional roles such as teachers or case managers, although it may include some aspects of these roles (Bailey, et.al., 1991; Hoberg-Arehart & Yoshinago-Itano, 1999; Kaiser & Hancock, 2003). Professionals who work with young children with disabilities must know how to partner with families, including working together to address child and family needs. Studies on parent participation indicate

then draw the attention of the child to the sound and to show them the source.

parents teach their children (Pinker, 1994, as cited in Clark, 2007).

Clark, 2007; Kaiser & Hester, 1995; Kaiser & Hancock, 2003; Wilson, 1998).

(Estabrooks, 2007; Clark, 2007; Lutherman, 2004).

inexperienced listener it is very difficult for a young child to know whom to attend to and it would deteriorate the intelligibility of the speech signals via hearing aids.

It helps in constant and efficient use of the hearing aids if parents are convinced that their baby can hear with the amplification (Clark, 2007; Cole & Flexer, 2007, Estabrooks, 2006). Often, early indications or clues of the child progressing are the most effective and immediate encouragement for the parents. This can be achieved by demonstrating the child's responses to the sound during the intervention and leading parents to observe their child's responses to the sound at home. The professional can guide the parents about early indicators of the child's hearing. These indicators include alertness to sound, turning to sound, quieting to sound, increased vocalizing, decreased vocalizing while listening and/or increased variety in vocalized sounds. The questions about child's responses to the sound help parents to observe more closely their child. Seeing the responses to the sound motivates parents in efficient use of hearing aids, they become sensitive for monitoring progress in the child.

#### **6.2 Intervention sessions**

Frequency, duration and place of an intervention session varies depending on the state policies in a given country and theoretical base and facilities of the intervention centres. Intervention could be home-based or centre-based, it could be once or twice in a week or a month (Department of Public Health, 2009; NDCS, 2004; Hogan, 2008).

Home based intervention has the advantage of knowing families' real life and planning the intervention accordingly. It is also possible to create close to natural environments at centre based programs. Duration of a session is usually reported 45 minutes to 1.5 hours (Brown & Nott, 2005; Clark, 2007, Estabrooks, 2006; Hogan, 2008).

In each session observing parents while interacting with the child is suggested (Brown & Nott, 2005; Clark, 2007; Estabrooks, 2007). Observing parents in interacting with the child serves several purposes. Firstly, the professional can evaluate the parents' strengths and weaknesses during their interaction with the child and guide the parents accordingly. Second, they have an opportunity to practice the new skills they acquired. Third it provides a chance to observe and monitor the progress in the child. It must be remembered that the main aim is to lead the parents toward confidence, competence and independence in handling their child with hearing loss (Bailey, 1998; Childress, 2004; DesJardin, et.al., Estabrooks, 2007; Kaiser & Hancock, 2005). Therefore all the positive aspects of the interaction should be mentioned and explained to the parents. The parents become more receptive to the suggestions given by the professional when they realize their strengths. In every session only one feature of what has been observed should be discussed for improvement (Clark, 2007).

The educational materials used in the sessions should be familiar and available at home. Using materials which are developmentally not appropriate to the child or are not available at home might be discouraging for the parents (Childress, 2004; Dunst, 2002; Mahoney, 2009; Odom& Wolery, 2003). Parents also may bring the toys, books or other materials to the session. For the babies younger than 6 months of age simple turn taking games, hiding and finding toys, popping up games and daily care routines of the infant can be used to interact in a language enabling way. When they grow a little older, simple household routines like sorting clothes to be washed, making fruit juice and tidying up can be performed. Parents

inexperienced listener it is very difficult for a young child to know whom to attend to and it

It helps in constant and efficient use of the hearing aids if parents are convinced that their baby can hear with the amplification (Clark, 2007; Cole & Flexer, 2007, Estabrooks, 2006). Often, early indications or clues of the child progressing are the most effective and immediate encouragement for the parents. This can be achieved by demonstrating the child's responses to the sound during the intervention and leading parents to observe their child's responses to the sound at home. The professional can guide the parents about early indicators of the child's hearing. These indicators include alertness to sound, turning to sound, quieting to sound, increased vocalizing, decreased vocalizing while listening and/or increased variety in vocalized sounds. The questions about child's responses to the sound help parents to observe more closely their child. Seeing the responses to the sound motivates parents in efficient use of hearing aids, they become sensitive for monitoring

Frequency, duration and place of an intervention session varies depending on the state policies in a given country and theoretical base and facilities of the intervention centres. Intervention could be home-based or centre-based, it could be once or twice in a week or a

Home based intervention has the advantage of knowing families' real life and planning the intervention accordingly. It is also possible to create close to natural environments at centre based programs. Duration of a session is usually reported 45 minutes to 1.5 hours (Brown &

In each session observing parents while interacting with the child is suggested (Brown & Nott, 2005; Clark, 2007; Estabrooks, 2007). Observing parents in interacting with the child serves several purposes. Firstly, the professional can evaluate the parents' strengths and weaknesses during their interaction with the child and guide the parents accordingly. Second, they have an opportunity to practice the new skills they acquired. Third it provides a chance to observe and monitor the progress in the child. It must be remembered that the main aim is to lead the parents toward confidence, competence and independence in handling their child with hearing loss (Bailey, 1998; Childress, 2004; DesJardin, et.al., Estabrooks, 2007; Kaiser & Hancock, 2005). Therefore all the positive aspects of the interaction should be mentioned and explained to the parents. The parents become more receptive to the suggestions given by the professional when they realize their strengths. In every session only one feature of what

The educational materials used in the sessions should be familiar and available at home. Using materials which are developmentally not appropriate to the child or are not available at home might be discouraging for the parents (Childress, 2004; Dunst, 2002; Mahoney, 2009; Odom& Wolery, 2003). Parents also may bring the toys, books or other materials to the session. For the babies younger than 6 months of age simple turn taking games, hiding and finding toys, popping up games and daily care routines of the infant can be used to interact in a language enabling way. When they grow a little older, simple household routines like sorting clothes to be washed, making fruit juice and tidying up can be performed. Parents

would deteriorate the intelligibility of the speech signals via hearing aids.

month (Department of Public Health, 2009; NDCS, 2004; Hogan, 2008).

has been observed should be discussed for improvement (Clark, 2007).

Nott, 2005; Clark, 2007, Estabrooks, 2006; Hogan, 2008).

progress in the child.

**6.2 Intervention sessions** 

must understand to recognize opportunities to facilitate language learning during the daily activities through following child's interest and being sensitive to communicative intentions of the child. Once parents understand to use language facilitating strategies in daily routines, they become active partners in creating these opportunities (Brown & Nott, 2005; Clark, 2007; Kaiser & Hester, 1995; Kaiser & Hancock, 2003; Wilson, 1998).

Some time during the session must be spent in discussing the things parents have done with the child since the last time they have been to the session. Also parents must be asked if they want to discuss any thing related to the child's development or progress. The parents should feel free to share their concerns or questions with the professional as well as positive signs of the progress. The professional should be able to refer parents to related professionals if their concerns are beyond the scope of the intervention process such as suspicion of a second handicap, neurological problems or necessity of psychiatric evaluation (Estabrooks, 2007; Clark, 2007; Lutherman, 2004).

Each session should include a musical activity or a listening game to improve listening skills of the child. Parents often need help to create suitable activities during the first few sessions. Therefore it is advised to dedicate time for age appropriate and enjoyable listening activities in each session. Parents must understand that these activities improve listening skills and are also enjoyable. Singing lullabies, rhymes and simple repetitive songs are highly recommended to widen the child's listening experience and to develop a sense of rhythm (Clark, 2007; Cole & Flexer, 2007; Estabrooks, 2007). Naturally occurring sounds at home such as door bell, telephone ring, and sounds from outside can also be used to develop listening skills. Parents are advised to listen to the sounds at home themselves first, then draw the attention of the child to the sound and to show them the source.

At the end of the session it is better to discuss language enabling activities and areas of language that might be focused at home. Caution should be taken that parents provide a language enhancing environment to the child. It must be remembered that language is a complex, specialized skill that develops in a child spontaneously and it is not something that parents teach their children (Pinker, 1994, as cited in Clark, 2007).

Sometimes it is better for the parents to see the professional interacting and talking with their child in a natural way. Professional's attitude towards the child encourages parent to expect age appropriate development. It is highly motivating especially after the diagnosis for some parents to see someone treating their child in a normal way who is not solely focusing on the hearing loss.
