Assessment of and Intervention with Children Who Are Deaf or Hard of Hearing

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The purpose of communication assessment of children with educationally significant hearing loss differs from the purpose of assessing children with language or learning disabilities. Since the diagnosis of a hearing disability has already been made, the primary goal of communication assessment is to determine the impact of the hearing loss on language, speech, auditory skills, or cognitive, social-emotional, educational and vocational development, not to diagnose a disability. It is critical to determine the rate of language and communication development and to identify strategies that will be most beneficial for optimal development.

Plateaus in language development at the 9-10-year age level, in reading development at the middle third grade to fourth grade level (Holt, 1993), and in speech intelligibility at about 10 years (Jensema, Karchmer, and Trybus, 1978) have been reported in the literature. The language plateaus appear to be the result of developmental growth, which ranges from 43%-53% for children with profound hearing loss using hearing aids (Boothroyd, Geers, and Moog, 1991; Geers and Moog, 1988) to 60%-65% of the normal range of development for children with severe loss using hearing aids (Booth-royd, Geers, and Moog, 1991) and for children with profound hearing loss using cochlear implants (Blamey et al., 2001). In contrast, in a study of 150 children, Yoshinaga-Itano et al. (1998) reported that children with hearing loss only who were early-identified (within the first 6 months of life) had mean language levels at 90% of the rate of normal language development through the first 3 years of life. A study of children in Nebraska (Moeller, 2000) reported similar levels of language development (low-average range) for a sample of 5-year-old children receiving early intervention services in the first 11 months of life. Later-identified children were able to achieve language development commensurate with the early-identified/intervened group when their families were rated as "high parent involvement'' in the intervention services.

With the advent of universal newborn hearing screening, the population of children who are deaf or hard of hearing will change rapidly during the next decade. By 2001, 35 states had passed legislation to establish universal newborn hearing screening programs, five additional states had legislation in progress, and five states had established programs without legislation. The age at which hearing loss is identified should drop dramatically throughout the United States, and this drop should be accompanied by intervention services, beginning in the newborn period. In the state of Colorado, infants referred from UNHS programs are being identified with hearing loss at 6-8 weeks of age and enter into intervention programs almost immediately thereafter.

For the population of children identified with hearing loss within the first 2 months of life, baseline communication assessments are typically conducted at 6-month intervals during the first 3 years of life (Stredler-Brown and Yoshinaga-Itano, 1994; Yoshinaga-Itano, 1994). Almost all of the infant assessment instruments are parent questionnaires that address the development of receptive and expressive language (e.g., MacArthur Communicative Development Inventories, Minnesota Child Development Inventory, Vineland Social Maturity Scales), auditory skills, early vocalizations, cognitive, fine motor, gross motor, self-help, and personal-social/ social-emotional issues. Videotaped analysis of parent-child interaction style and spontaneous speech and language production is frequently included.

Spontaneous speech samples should be analyzed to identify the number of different consonant phones. The number of different consonant phones produced in a spontaneous 30-minute language sample taken in the home between 9 months and 50 months of age is a good predictor of speech intelligibility (Yoshinaga-Itano and Sedey, 2000). The primary development of speech for children with mild to moderate hearing loss is concentrated between 2 and 3 years of age, while the preschool years, ages 3-5 years, are a significant growth period for children with moderate to severe hearing loss. Speech development for children with profound hearing loss who use hearing aids is very slow in the first 5 years of life. Although 75% of children with mild through severe hearing loss achieved intelligible speech by 5 years of age, only 20% of children with profound hearing loss who used conventional amplification achieved this level by age 5. Level of expressive language and degree of hearing loss were the two primary predictors of speech intelligibility.

Videotaped interactions of parent-child communication can be analyzed for maternal bonding and emotional availability (Pressman et al., 1999), turn-taking (Musselman and Churchill, 1991), use of pause time, maintenance of topic, topic initiation, attention-getting devices, the development of symbolic play, symbolic gesture, and communication intention strategies (comments, requests, answers, commands) of both the parent and the child (Yoshinaga-Itano, 1994). These analyses provide important information for the family and intervention provider to help design strategies for optimal development. Reciprocal relationships have been reported. Parents adjust language as their child's language improves (Cross, Johnson-Morris, and Nienhuys, 1985), and low levels of maternal turn control are asso ciated with greater gains in expressive language (Mus-selman and Churchill, 1991). At present, studies of causality have been insufficient to determine the efficacy or superiority of various intervention strategies. However, some interventions that are theoretically grounded and are characteristic of programs that demonstrate optimal language development are parent-centered, provide objective developmental data, assist parental decisions about methodology, based on the developmental progress of the individual child, include a strong counseling component aimed at reducing parental stress and assisting parents in the resolution of their grief, and provide guidance in parent-child interaction strategies.

The language development of early-identified (within the first 6 months of life) children with hearing loss is similar to their nonverbal development, particularly in regard to symbolic play development (Snyder and Yoshinaga-Itano, 1999; Yoshinaga-Itano and Snyder, 1999; Mayne et al., 2000). About 60% of the variance in early language development is predicted by nonverbal cognitive measures such as symbolic play and age at identification of hearing loss. Mode of communication, degree of hearing loss, socioeconomic status, ethnicity, and sex were not shown to predict language development. These results contrast sharply with the school-age literature, in which race, ethnicity, and socioeconomic status are primary predictors of reading achievement (Holt, 1993).

In order to maintain the successful language development of the early-identified children, the purpose of evaluation in the first 5 years of life should be to monitor and chart the longitudinal developmental progress of the child, with two primary goals: (1) to achieve language development commensurate with nonverbal cognitive development, and (2) to achieve language development in children with hearing loss only, within the normal range of development. In an analysis of almost 250 children, an 80% probability of language within the low-normal range in the first 5 years of life was reported if a child identified with hearing loss had been born in a Colorado hospital with a universal newborn hearing screening program (Yoshinaga-Itano, Coulter, and Thomson, 2000).

In addition to an analysis of communication skills, cognitive development, and age at identification, assessments should include information about the social-emotional development of both parents and children. Relationships have been found between language development and parental stress (Pipp-Siegel, Sedey, and Yoshinaga-Itano, 2002), emotional availability (Pressman et al., 1999) parent involvement (Moeller, 2000), grief resolution (Pipp-Siegel, 2000), development of sense of self (Pressman, 2000), and mastery motivation (Pipp-Siegel et al., 2002). The relationships examined in these studies do not establish causes, but it is plausible that intervention strategies focused on these areas may enhance the language development of young children with hearing loss. Counseling strategies with parent sign language instruction enhanced language development

Assessment of and Intervention with Children Who Are Deaf or Hard of Hearing 423

among children using total communication (Greenberg, Calderon, and Kusche, 1984).

Assessment strategies during the preschool period, ages 3-5 years, continue to focus on receptive and expressive vocabulary, but their primary focus shifts to the development of syntax and morphology and pragmatic language skills (Yoshinaga-Itano, 1999). Spontaneous language sample analysis is recommended for expressive syntax analysis. There is a shift from parent questionnaire developmental assessments and assessments of spontaneous communication to clinical or school-based elicited assessments at this age period. Testers need to ensure full access to the information being presented, either through fully functioning amplification devices, adequate speech reading accessibility, or the skills of a fluent signer.

During the school-age period, standardized assessments consist of regularly administered tests of language (receptive and expressive vocabulary, syntax, pragmatics, and phonology), reading and writing, mathematics, other content areas, and social-emotional development (Yoshinaga-Itano, 1997). Researchers hypothesize that there may be as many as four possible routes to literacy for children with hearing loss: (1) spoken language to printed language decoded to speech, (2) English-based signs to printed English, (3) American Sign Language (ASL) to print, with English-based signs as an intermediary, and (4) ASL to print (Mussel-man, 2000). Assessments of knowledge of English semantics, syntax, and phonological processing, accuracy and speed of word identification, and orthographic encoding should be included, since several studies have found that these variables are significantly related to reading comprehension (Musselman, 2000). Among children who use sign language, finger-spelling ability and general language competence in either ASL or English should be included (Musselman, 2000). For all children, assessments should also focus on the metalinguistic and metacognitive strategies (knowing how to use and think about language) used by the students in person-to-person and written communication (Gray and Hosie, 1996). "Theory of mind'' assessments provide information about the cognitive ability of the student to understand a variety of different perspectives (Strassman, 1997). Students need to develop strategies to acquire and elaborate world knowledge, elaborate vocabulary knowledge (both conversational and written), and to use this knowledge to make inferences in social, communicative interactions and reading/ academic situations (Paul, 1996; Jackson, Paul, and Smith, 1997).

—Christine Yoshinaga-Itano

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