Today, I have one thing on my mind…birthdays. That’s because today is my birthday. While my birthday really has nothing to do with hearing loss and speech or this site at all, it got me thinking. There is always talk about a child’s hearing birthday. How much does the child’s hearing birthday play into determining if the child is meeting expectations. Is it all about that date? Or is there more to it?
Research has shown that children with cochlear implants have the ability to catch up to their peers in terms of listening, speech, and language skills. But is that the case for every child? What types of things might hinder progress or contribute to the child’s expected outcome?
Before we begin a discussion about expected outcome, we must define “meeting expectations”. Whose expectations? The end goal may be very different for different families. Some parents may hope that their child function in line with typically hearing peers in every way, including being mainstreamed with use of verbal language. While other parents may want their child to identify with his/her hearing loss and the Deaf community via ASL, while providing access to sounds and speech with amplification Unfortunately, it is very difficult to have a discussion about expected outcomes looking through a variety of different lenses. So, for the purposes of this article, I am discussing the former, families expectations of a child to become mainstreamed, caught up with peers and a verbal communicator.
So, What Factors Do We Need to Consider As We Determine If An Individual Child is Meeting Expectations?
Chronological age is the child’s actual age based upon birth date. Obviously, we must take current biological age into account when determining if a child is meeting expectations with technology. We would expect very different skills from a child who is 2 years old than we would of a 5 year old child with the same technology experience. Discrete listening skills as per the auditory hierarchy might be similar (see article on Auditory Hierarchy), but activities related to the task would be different. Our speech production expectations would be different as well. A two year old typically hearing child is not yet expected to produce /f/, so we wouldn’t expect this of the two year old with hearing loss, but we might expect it of the 5 year old with hearing loss.
In the field, professionals like to speak of hearing age, the amount of time that has passed since the child was amplified. For some children, there is a clear cut date to use to calculate hearing age. For example, consider a child born profoundly deaf, who receives little to no benefit from hearing aids and then who is implanted with a cochlear implant at 12 months of age. On the date of activation, the “clock” begins and this becomes the child’s hearing birthday. However, for many children, it is not this straightforward. I have worked with children who had been amplified from a very young age (a few months), but at the around the age of 3, more accurate testing was obtained (new audiologist or child more reliable) and then the child was fit with more optimal amplification. What date do we use in this scenario? Or, what about the child with progressive hearing loss who then gets a cochlear implant? Is the hearing age the original age of amplification or the age of implantation? For this child, if we think about the original age of appropriate amplification as the hearing age (because this is when the child began to have good access to spoken language), would our expectations of post implant be appropriate if based upon hearing age?
Aided hearing refers to the child’s aided access to sound. We must look at the audiogram and thresholds with amplification to determine if the child has optimal access to speech. Expected levels of performance will obviously be different for a child whose aided thresholds are at the top of the speech banana (the area on the audiogram that represents speech sounds) from the child whose thresholds are at the bottom of the speech banana or the child who does not have access within the speech banana at very high frequencies. For this child, can we expect auditory comprehension and speech production to be excellent? Likely not.
While every family has the right to determine what works best for their own child and which mode of communication to use, the chosen mode of communication definitely impacts the auditory outcome of the child. This can become a controversial discussion, but for the purposes of this article, we are looking towards the goal of the child becoming a verbal communicator and mainstreamed with as little support as possible. With that in mind, a child who uses an auditory verbal approach to listening and spoken language development would be expected to have more developed listening and verbal language skills than the child who is being taught via total communication.
Medical/Structural Cause of Hearing Loss
For some children, the cause of hearing loss has been determined and it is due to a structural anomaly. These structural issues may alter expectations based upon the child’s ability to benefit optimally from amplification. For example, ossification of the cochlea (when the cochlea hardens into a bony structure) after meningitis is common. While this does not impede candidacy, it may cause signal transmission from the electrodes to the auditory nerve to be poorer. Other structural anomalies, such as a small auditory nerve, may also be consistent with poorer results.
Knowledge of a child’s cognitive skills is critical in determining outcomes. While a precise cognitive score is not necessary, understanding of the child’s overall cognitive level is helpful. If there are cognitive limitations, sometimes the best auditory access won’t be enough for the child to become mainstreamed and a verbal communicator. This is not to say that implanting these children is not recommended. It is that we must be realistic as to how they may use the auditory information.
If other disabilities are present this will also impact prognosis. Autism, ADHD, Down Syndrome, and other diagnoses all have their own expected outcomes in terms of listening, speech and language skills. We can not expect that the cochlear implant will ‘cure” each of these and provide the child with better outcomes than peers with the same diagnoses.
Prior Language Experience
Some children have receptive and/or expressive language prior to optimal amplification. This could be because the hearing loss was progressive in nature. Some children use total communication (including sign) prior to optimal amplification. Any of these could help to bridge the gap and speed up progress. Consider a child who began to develop language and then lost his/her hearing at 4 or 5 years of age due to meningitis. If implanted immediately, we might expect faster progress through the auditory hierarchy, as the auditory pathways were already developed. Language expectations would also be excellent as the child had language prior to the implant.
Of course, good therapy and a school program that is working to maximize potential with audition is important. The child working with an experienced therapist who knows how to work on listening and spoken language, as it relates to hearing loss, will more than likely be able to make faster progress and meet expectations. Parent participation another important factor. A therapist only spends a fraction of a child’s week with the child. If the parent is trained, via participation in therapy sessions, and provided with activities to do all week long, auditory therapy is happening around the clock and we can expect greater progress.
It’s NOT All About That Date
So, as my birthday winds down, I appreciate the one time per year that I hear from people far and wide sharing their wishes. Children with hearing loss are lucky to have two different birthdays to celebrate. However, I think that it is fair to say, that there is more to determining if a child is meeting expectations than relying on the hearing birth date and the time that has passed since amplification. That being said, I think parents of children with hearing loss have so much to be thankful for and should CELEBRATE each and every success and milestone.