**3. Language development in infancy**

118 Hearing Loss

Like other areas of special education the necessity for early identification and intervention for language development of children with a hearing loss has long been realized and auditory oral/verbal programs have offered intervention for parents to development of spoken language of their children. However progress in universal newborn hearing screening has altered the age range that professionals used to work with. They have to deal much younger children than the past. The advancement in hearing technology has increased the hearing capacity of these young children. Digital hearing aids and cochlear implants provide richer stimuli than ever. Therefore it seems necessary to reconsider the intervention

approaches regarding the age of these children and the new role of the professional.

**2. Early identification of a hearing loss** 

skills.

later than 6 months of age.

In this chapter the basic issues on the early management of a hearing loss and the rationale of family based services will be described, the professional's role as a partner with parents in early intervention for babies with a hearing loss will be discussed and the factors which facilitate language development and their use in intervention process will be summarized.

Hearing loss which occurs congenitally or early in life prevents language development in its normal discourse since hearing is our primary sense to acquire spoken language. Therefore some steps should be taken to help babies with hearing loss to achieve speech and language

It has been widely acknowledged that children born with a hearing loss can acquire and develop spoken language if they are identified and fitted with appropriate hearing technology early in their lives and receive quality intervention services (Clark, 2007; Cole & Flexer, 2007; DesJardin, et. al., 2006; Estabrooks, 2006). Younger the age of diagnosis and intervention, better the development of spoken language (White, 2006; Yosinago-Itano & Apuzzo, 1998; Yosinago-Itano & Sedey, 2000). For this reason, it is aimed to identify and fit the hearing aids within the first 3 months of life and to start the intervention program no

Technology for automated hearing screening with otoacoustic emissions (OAE) and with auditory brainstem responses (ABR) permits fast, accurate and cost-effective identification of hearing loss in infants within hours after their birth. During the last two decades universal newborn hearing screening (UNHS) were supported as official policy in most developed countries (Department of Public Health, 2009; NDCS; 2004). It is also steadily expanding in developing countries; giving way to early identification and management of

Early identification and fitting of hearing aids/cochlear implant provide opportunities to stimulate auditory pathways during the critical periods of language acquisition and enables normal development of language. Although it is flawed, sensory stimulation which is provided through the hearing aids or cochlear implants supports the development of the neural network within the auditory system (Ryugo, et.al., 2000). On the other hand, a language enhancing environment should also be created to make maximum use of the sensory stimulation since learning is required for language acquisition (Clark, 2007; Cole &

any kind of a hearing loss in infants and young children throughout the world.

In course of language development the first two years of life are seen to be critical.

Flexer, 2007; Lieven, 1994; Otto, 2006 ; Sokolov & Snow, 1994).

Language development is one of the most remarkable achievements in childhood. Sometime during their second year most children begin to talk and apparently little time is required in using language to address their needs and carry on social interactions. During the last 50 years language acquisition has been studied with respect to what is learned, when it is learned and what factors or variables seem to explain the process of acquisition. While no single theory provides complete and irrefutable explanation of language acquisition, each theory contributes significant ideas and concepts which over time has clarified the awareness of the ways language is acquired (Bloom, 1993; Otto, 2006; Pine, 1994; Rice, 1996).

Theories which try to explain the language acquisition can be summarized under four broad categories. The nativist and the cognitive developmentalist perspectives emphasize the contributions of "nature" whereas the behaviourist and interactionist perspectives focus more on "nurture".

*Nativist* perspective emphasizes inborn or innate human capabilities as being responsible for language acquisition. Linguist Noam Chomsky is the major theorist associated with the nativist perspective. He contends that all people inherently have the capacity to acquire language due to cognitive structures that process language differently from other stimuli (Otto, 2006). A major focus of the nativist perspective is on the acquisition of syntactic knowledge. Semantic knowledge is also considered with respect to its relation to syntax (Pool, 2005). Chomsky proposes that universal grammar which is "the system of principles, conditions and rules that are elements or properties of all human languages" (Chomsky, 1975, as cited in Otto, 2006). As evidence of the universality and instinctive nature of language it is argued that no mute civilizations have ever been discovered throughout history. Since language exists in every culture it is concluded that it must arise from human biological instinct rather than from the existence of the culture (Otto, 2006).

*Cognitive* developmental perspective is based on the work of Jean Piaget (Baldwin, 2005). The emphasis of this perspective is that language is acquired as maturation occurs and cognitive competencies develop. While the nativist perspective emphasizes the inborn language mechanism, the cognitive developmental perspective assumes that cognitive development is a prerequisite and foundation for language learning. This perspective proposes that language is learned using the same learning mechanisms that the child uses for other learning. Thus there is no unique language mechanism. The close relation between the cognitive development and language is based on the belief that, for language to develop, specific cognitive growth must occur first (Baldwin, 2005; Bloom, 1995).

*Behaviourist* perspective states that learning occurs due to associations established among stimuli, responses and events that occur after the response behaviour. Language is learned as a result of these associations. The child is considered to be a "blank slate" and reinforcement of a child's verbal and nonverbal responses to language directed at him is responsible for language learning. Thus language is "taught" through situations in which children are encouraged to imitate other's speech and to develop associations between verbal stimuli and objects. Reinforcement often takes the form of attention, repetition and approval. This kind of learning is called operant conditioning. The use of the word "operant" acknowledges the child's active role in the learning process. It occurs when environmental consequences occur that are contingent on the specific behaviour. For example when an infant is producing sound and says "ma-ma" the parent may rush to the

Early Intervention with Children

subculture of which it forms a part (Lieven, 1994).

intention between the adult and the child.

Who Have a Hearing Loss: Role of the Professional and Parent Participation 121

utterances and simple sentences. It is characteristically higher in pitch, more exaggerated in intonation and slower in tempo than speech among adults. It is highly redundant with lots of repetitions and closely tied to the immediate context (Bornstein & Tamis-LeMonda, 1997; Bornstein, et.al., 1999; Pine, 1994). This kind of speech is called "motherese" or child directed speech by several reserchers (Cole &Flexer, 2007, Eastabrooks, 2006; Otto, 2006; Pine, 1994). To answer the reasons for using speech adjustments several explanations were suggested and a general consensus is reached arguing that speech adjustment to young children are motivated by a desire to communicate rather than to teach the language (Bruner, 1990; Cole & Flexer, 2007; Lieven, 1994; Pine, 1994; Sokolov & Snow, 1994). It is suggested that these adjustments have two main functions: the facilitation of understanding and sustaining of attention (Cole & Flexer, 2007; Pine, 1994). It has a conversational nature but at the same time it helps to direct and control child's behaviour (Bornstein & Tamis-LeMonda, 1997; Bornstein, et.al., 1999). The speech adjustment can be properly understood by putting it back to the context in which it occurs but the context is itself multifaceted and extends far beyond the dyad itself, not only to the family in which child is growing up, but also to the culture or

Young children's social and communicative skills were also found to be more precocious than their language skills during their interactions with adults and argued that it could serve as a facilitative source for language development (Bruner, 1983; 1990). Children were seen as active learners in interaction process rather than passive learners. The term "cognitive apprenticeship" is used to explain the child's learning and problem solving from "*actively* observing and participating in culturally defined problems with more skilled members in their society" (Sokolov & Snow, 1994, p. 44). Based on these observations, the connection between prelinguistic communicative intents in children and adults were studied widely in early language development and it was suggested that what children acquire and encounter is "language in use" during the language development process (Halliday, 1996). Language is a resource for making meaning and meaning is reflexive of the context. It is social, semantic and holistic (Thompson, 2005). Therefore communication and context of conversational interaction is central in the acquisition of language and the data from controlled experiments must be completed by observational studies of children in their natural environments as well (Halliday, 1996). Bruner (1983) supported this view and argued that the study of communicative precursors to formal language was important and quite independent of the nature-nurture controversy suggesting to concentrate more on

These summarized concepts are also relevant to intervention practices for children with a hearing loss (Brown & Nott, 2005; Clark, 2007; Estabrooks, 2006; Sokolov & Snow, 1994) especially for the ones before 3 years of age. Basic assumption is that if adequate auditory and linguistic experience is provided to most children who have hearing loss from an early age; cognitive and linguistic functioning can be expected to follow the normal course of development (Clark, 2007; Geers, 2004, as cited in Cole and Flexer, 2007; Houston, et.al., 2003; Moller, 2000; Rice & Lenihan, 2005; Spencer, 2004; Wallace, et.al., 2000; Warren, 2000). The most reasonable course to follow in carrying out intervention is, establishing a normal language learning environment (Brown & Nott, 2005; Clark, 2007; Cole & Flexer, 2007; Hogan. et.al., 2008). The sequence of language learning is expected to include normal processes such as the intertwining of linguistic and cognitive activity. Parents are the social

infant, show signs of delight and say "Oh, you said ma-ma". This positive response from the parent increases the chances the infant will repeat these sounds. Likewise, speech that elicits no response or ignored is less likely to be repeated (Otto, 2006).

*Interactionist* approach contends that children acquire language through their attempts to communicate with the world around them. Sociocultural interaction has the primary role and therefore is the main focus of this perspective. Language is acquired by individuals out of a need to function in society and an accompanying need for knowledge of how language functions in that society (Halliday, 1996). The primary role of social interaction in language acquisition is based on the observation that children acquire an awareness of specific communicative functions or intentions (such as indicating, requesting and labelling) before they are able to express themselves linguistically. This can be seen in the joint attention and verbal turn taking that often occurs between prelinguistic infants and their parents or caregivers (Bruner, 1983; 1990). These early understandings of how language functions provide a foundation on which the linguistic competencies are acquired. Environmental supports for language acquisition can be observed in the interaction patterns found in conversations such as listening, responding to what was said, repeating for clarification and asking questions (Cole & Flexer, 2007). Another important aspect of this approach is its focus on the language as *process* of acquisition rather than the language as *product* (Otto, 2006).

Overall the outcomes of research which has different theoretical backgrounds indicates that there is remarkable similarity in the general acquisition sequence for language skills across language and cultures although there is considerable individual variability in language learning strategies and rate of acquisition (Lieven, 1994; Pine, 1994). It is clear that children learn language as a means of talking about what they know so they can accomplish social goals important to them (Halliday, 1996; Thompson, 2005; Vygotsky, 1996) and it is agreed that language emerges from the child's explorations of the world in a rich social setting (Baldwin, 2005; Bloom, 1993; Rice, 1996).

Current thinking behind the language intervention for babies and young children with a hearing loss is more closer to interactionist view suggests that children with a hearing loss have the same innate capacity to develop fluent spoken language as do children with normal hearing provided that they are given the same opportunities (Childress, 2004; Clark, 2007; Cole & Flexer, 2007; ). Clark (2007) states that "same opportunity"is sometimes difficult to create. Because knowledge of the presence of a hearing loss in a child often puts pressure on the significant adults in the child's environment. The pressure that parents experience usually lead them to alter their natural interaction with their baby. The purpose of early intervention was therefore defined as to support and assist families in providing language learning opportunities for their infant within the activities, routines and events of everyday life in an interactional natural way rather than "teaching language". The professionals who work in early intervention should be guiding and coaching parents to establish an appropriate quality interaction with their babies (Bailey et. al., 1991; Baguley & Bamford, 2000; Clark, 2007; DesJardin, et.al, 2006; Mahoney & Perales, 2003; Mahoney 2009; White, 2006).

#### **4. Parent-child interaction in language development and early intervention**

Studies concentrated on parent-child interaction in language development indicate that there are some speech adjustments which adults make when they interact with young language learners. The speech addressed to children consists of short, well-formed

infant, show signs of delight and say "Oh, you said ma-ma". This positive response from the parent increases the chances the infant will repeat these sounds. Likewise, speech that elicits

*Interactionist* approach contends that children acquire language through their attempts to communicate with the world around them. Sociocultural interaction has the primary role and therefore is the main focus of this perspective. Language is acquired by individuals out of a need to function in society and an accompanying need for knowledge of how language functions in that society (Halliday, 1996). The primary role of social interaction in language acquisition is based on the observation that children acquire an awareness of specific communicative functions or intentions (such as indicating, requesting and labelling) before they are able to express themselves linguistically. This can be seen in the joint attention and verbal turn taking that often occurs between prelinguistic infants and their parents or caregivers (Bruner, 1983; 1990). These early understandings of how language functions provide a foundation on which the linguistic competencies are acquired. Environmental supports for language acquisition can be observed in the interaction patterns found in conversations such as listening, responding to what was said, repeating for clarification and asking questions (Cole & Flexer, 2007). Another important aspect of this approach is its focus on the language as *process* of acquisition rather than the language as *product* (Otto, 2006).

Overall the outcomes of research which has different theoretical backgrounds indicates that there is remarkable similarity in the general acquisition sequence for language skills across language and cultures although there is considerable individual variability in language learning strategies and rate of acquisition (Lieven, 1994; Pine, 1994). It is clear that children learn language as a means of talking about what they know so they can accomplish social goals important to them (Halliday, 1996; Thompson, 2005; Vygotsky, 1996) and it is agreed that language emerges from the child's explorations of the world in a rich social setting

Current thinking behind the language intervention for babies and young children with a hearing loss is more closer to interactionist view suggests that children with a hearing loss have the same innate capacity to develop fluent spoken language as do children with normal hearing provided that they are given the same opportunities (Childress, 2004; Clark, 2007; Cole & Flexer, 2007; ). Clark (2007) states that "same opportunity"is sometimes difficult to create. Because knowledge of the presence of a hearing loss in a child often puts pressure on the significant adults in the child's environment. The pressure that parents experience usually lead them to alter their natural interaction with their baby. The purpose of early intervention was therefore defined as to support and assist families in providing language learning opportunities for their infant within the activities, routines and events of everyday life in an interactional natural way rather than "teaching language". The professionals who work in early intervention should be guiding and coaching parents to establish an appropriate quality interaction with their babies (Bailey et. al., 1991; Baguley & Bamford, 2000; Clark,

2007; DesJardin, et.al, 2006; Mahoney & Perales, 2003; Mahoney 2009; White, 2006).

**4. Parent-child interaction in language development and early intervention**  Studies concentrated on parent-child interaction in language development indicate that there are some speech adjustments which adults make when they interact with young language learners. The speech addressed to children consists of short, well-formed

no response or ignored is less likely to be repeated (Otto, 2006).

(Baldwin, 2005; Bloom, 1993; Rice, 1996).

utterances and simple sentences. It is characteristically higher in pitch, more exaggerated in intonation and slower in tempo than speech among adults. It is highly redundant with lots of repetitions and closely tied to the immediate context (Bornstein & Tamis-LeMonda, 1997; Bornstein, et.al., 1999; Pine, 1994). This kind of speech is called "motherese" or child directed speech by several reserchers (Cole &Flexer, 2007, Eastabrooks, 2006; Otto, 2006; Pine, 1994).

To answer the reasons for using speech adjustments several explanations were suggested and a general consensus is reached arguing that speech adjustment to young children are motivated by a desire to communicate rather than to teach the language (Bruner, 1990; Cole & Flexer, 2007; Lieven, 1994; Pine, 1994; Sokolov & Snow, 1994). It is suggested that these adjustments have two main functions: the facilitation of understanding and sustaining of attention (Cole & Flexer, 2007; Pine, 1994). It has a conversational nature but at the same time it helps to direct and control child's behaviour (Bornstein & Tamis-LeMonda, 1997; Bornstein, et.al., 1999). The speech adjustment can be properly understood by putting it back to the context in which it occurs but the context is itself multifaceted and extends far beyond the dyad itself, not only to the family in which child is growing up, but also to the culture or subculture of which it forms a part (Lieven, 1994).

Young children's social and communicative skills were also found to be more precocious than their language skills during their interactions with adults and argued that it could serve as a facilitative source for language development (Bruner, 1983; 1990). Children were seen as active learners in interaction process rather than passive learners. The term "cognitive apprenticeship" is used to explain the child's learning and problem solving from "*actively* observing and participating in culturally defined problems with more skilled members in their society" (Sokolov & Snow, 1994, p. 44). Based on these observations, the connection between prelinguistic communicative intents in children and adults were studied widely in early language development and it was suggested that what children acquire and encounter is "language in use" during the language development process (Halliday, 1996). Language is a resource for making meaning and meaning is reflexive of the context. It is social, semantic and holistic (Thompson, 2005). Therefore communication and context of conversational interaction is central in the acquisition of language and the data from controlled experiments must be completed by observational studies of children in their natural environments as well (Halliday, 1996). Bruner (1983) supported this view and argued that the study of communicative precursors to formal language was important and quite independent of the nature-nurture controversy suggesting to concentrate more on intention between the adult and the child.

These summarized concepts are also relevant to intervention practices for children with a hearing loss (Brown & Nott, 2005; Clark, 2007; Estabrooks, 2006; Sokolov & Snow, 1994) especially for the ones before 3 years of age. Basic assumption is that if adequate auditory and linguistic experience is provided to most children who have hearing loss from an early age; cognitive and linguistic functioning can be expected to follow the normal course of development (Clark, 2007; Geers, 2004, as cited in Cole and Flexer, 2007; Houston, et.al., 2003; Moller, 2000; Rice & Lenihan, 2005; Spencer, 2004; Wallace, et.al., 2000; Warren, 2000).

The most reasonable course to follow in carrying out intervention is, establishing a normal language learning environment (Brown & Nott, 2005; Clark, 2007; Cole & Flexer, 2007; Hogan. et.al., 2008). The sequence of language learning is expected to include normal processes such as the intertwining of linguistic and cognitive activity. Parents are the social

Early Intervention with Children

the day has the utmost importance.

**6.1 Amplification and listening environment** 

keep supplying the power during the day.

**6. Management and practical aspects in intervention** 

Who Have a Hearing Loss: Role of the Professional and Parent Participation 123

minute, but to select or create opportunities for verbal interaction (Cole & Flexer, 2007). Auditory stimulation is the base of these kind of intervention and if language acquisition through audition is attempted, correct use of hearing aids or cochlear implants throughout

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

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

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

in their cribs. It is also advised to use a FM system in noisy conditions.

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