As both a speech/language pathologist and audiologist, the author of this manual is clinically aware of what amplification can and can't do for individuals who are hearing impaired. No generalization concerning the efficacy of amplification is either possible or desirable because every individual has different needs at different times in life. Some are marvelously helped by amplification, and some find amplification physically painful and of no help at all. The majority who have experienced amplification in some form fall somewhere between the two extremes. This writer has deliberately avoided equating "hearing aids" with "amplification" because he is not yet convinced that the "aids" as presently manufactured and widely advertised meet the complex and varying needs of the developing child in every situation. Other forms of acoustical imput may be far more efficient for certain perceptual tasks -- including the initial perception of speech. Compared to the availability of instruments on the market to enhance visual information, the hearing enhancement business is still in its infancy. Wearable hearing aids are designed primarily for the adventitious hearing loss of adults -- because that's where the market is. But this is no reason to abandon either "aids" or amplification for young children. It is an excellent reason for keeping a close check on current needs and the instruments available to fill those needs.
Those who have chosen to use Cued Speech as a supplementary strategy for ensuring the development of receptive oral language are usually people who realize that -- for their hearing-impaired child -- amplification simply isn't doing the whole job efficiently. But that realization is no excuse for discounting or abandoning amplification on all counts. Too much is at stake for the child who is entitled to speak the oral language of his/her culture as well as receive it. Personally, the author doesn't know of any parent, teacher, or clinician who has abandoned amplification in favor of Cued Speech exclusively. There are many good reasons for not ignoring residual hearing and for seeking periodic audiologic evaluations.
1. Cued Speech has limitations which often -- if not always -- could be eliminated with judicious amplification. True, cueing spoken syllables displays the phonemes of a given oral language with great fidelity. But Cued Speech is less effective in displaying syllabic stress, and of questionable value in displaying allophones, pitch levels, intonation across syllables, loudness, and vocal quality. Fortunately, even the most limited residual hearing can provide valuable perceptions of pitch, intonation, stress patterns, and relative loudness of voice. Voice quality and subtle phoneme variations usually require more residual hearing. Ironically, the child who really can hear pitch, intonation, and stress patterns may ignore what he hears because the syllables are meaningless. But with Cued Speech to provide syllable meaning and amplification to provide synchronized pitch, intonation and stress patterns, residual hearing begins to make sense. Listening to aural stimuli with Cued Speech can pay off!
2. The fears of some professionals that Cued Speech might encourage hearing-impaired individuals to ignore their residual hearing could be valid. It is our responsibility as parents, teachers, and clinicians to make sure this never happens. Arbitarily abandoning amplification could cheat the individual out of vital and valuable information about speech and about non=speech auditory experiences. Until there is real evidence to the contrary (Granted, sometimes there is!) we must not run that risk.
3. Just because the hearing-impaired child is progressing nicely with receptrive oral language development is no excuse for leaving auditory training and speechreading to chance. The most comprehensive programs which used Cued Speech include auditory training experiences and checks within the curriculum. Parents of pre-school children should heed the suggestions of such excellent resources as the Tracey Home Study Program and the writings of the Ewings, Pollack, Griffiths, Downs, and many others. Most speech/language clinicians and audiologists are familiar with auditory training techniques and can help. A.G. Bell catalogs always list excellent auditory training books and monographs.
Amplification of any type for hearing-impaired children should be carefully monitored periodically. How often? The author suggests at least once a month until one knows how the child is responding. Then evaluation can be spaced at three to six month intervals unless there is a hearing crisis, Obviously, the functional integrity of the amplification unit must be checked daily for very small children or for those whose response to wearable aids is inconclusive. Our concern here (assuming that the device is working properly) is the benefit of amplification for the child who is also receiving Cued Speech.
The author devised a "Monthly Hearing Evaluation" program for use in a school for the Deaf some years ago. What follows is a modification of that program which can be conducted by a parent, teacher, or speech/language clinician. Make sure that whoever does the evaluation knows what questions you want answered about your child's responses to amplification. Show them a copy of the Monthly Hearing Evaluation so that they will know what information you expect.
The following questions and strategies assume that amplification was recommended for your child by a physician and prescribed by a licensed or ASHA-certified audiologist.
1. Does amplification allow your child to locate environmental sounds excluding speech? Even infants will seek out with their eyes such noises as starting cars, vacuum cleaners, rumbling trucks, telephone bells, footsteps, etc. This is a behavior which sould occur very quickly after amplification is introduced. If it doesn't, the fault may lie in the type of amplification. Check back with the person who recommended the device and don't take "eventually he will learn to locate sounds" for an answer! Locating sounds in space is not a learned response.
2. Does amplification allow your child to locate speech in space? Can the child turn to ther person speaking with auditory cues alone? If so, this is an important "plus" for the Cued Speech child. Amplification and Cued Speech will be working together even if amplificaiton alone does not allow the child to decode what the speaker is saying.
3. Does amplification promote discrimination of gross environmental sounds?Does the door bell produce a different response from the vacuum cleaner or kitchen disposal? Is a dog bark differentiated from a door slam? Is thunder perceived as different from a truck rumbling by the house? Gross environmental sounds usually have a strong low frequency component or differ markedly in duration, pulse pattern, and the like. Again, children should respond rather quickly to such sounds in a meaningful way if amplification is doing the job.
4. Does amplificaion promote discrimination of sophisticated environmental sounds? Do electric shavers, blow dryers, and blenders each have a different aural significance for the child? How do you know? Can bells at different pitches be discriminated? Is the front door chime different from the back door chime in pattern? Children who gain such subtle information from amplification should certainly be encouraged to stay with it -- even if speech discrimination without Cued Speech is very poor.
5. Can the child recognize spoken vowels without speechreading information on the lips? Cued Speech may well have helped to establish the vowels, but how accurately does the child respond with amplification alone? Check the low Hz vowels /ue/, /oo/, /oh/, /aw/, and /ah/ first. You should have accurate responses if amplification is of any assistance. Then include the vowels with a high Hz format such as /ee/, /i/, /e/ and /ur/. If the child can respond accurately to these as well, amplification will be vital to future training. If the child is having trouble with the latter vowel sounds, you would be very wise to check the appropriateness of the amplification device before assuming that the child simply "can't hear."
6. Can the child recognize diphthongs with amplification alone? Check such speech sounds which have been cued to the child (/ie/, /ay/, /oi/, /ow/ plus /er/, /ir/, /oor/, and /awr/) for auditory discrimination. What real words could you use?
"bye-bye" "boy" "baby" "bow-wow" "bear" "deer" "door" "cow" "kite"
These may require some learning with amplification on the part of the child, so don't expect immediate accuracy. Don't even expect long term accuracy if the results of preceding oservations have been marginal.
7. Can the child recognize low Hz consonants with amplification? Such words as "moon," "Mom," "moo," "zoo," "doll" should be tried. Again, Cued Speech will have prepared the child with a meaningful vocabulary from which to draw stimulus words for discrimination. Cue such words to the child first -- use picture pointing to check responses -- and then present them without oral/visual cues of any sort.
8. Can the child recognize high Hz consonants with amplification? Such words as "suit," "thumb," "fire," "shirt," "shoe" can be used as stimuli. Make sure the child knows the vocabulary words via cueing, and then check with picture or object identification tasks. Don't let the child see your face when presenting words to check the efficacy of amplification.
9. Does your child recognize singing patterns? Hopefully you have been cueing and singing nursery songs and other ditties for and with your child. If you sing or hum without words, can the child identify the song? If so, then amplification is providing extremely valuable sound patterns. These patterns must of course be learned by the child. Don't expect instant results. A few weeks of play-practice with the songs should produce some positive results if amplification is really supportive.
10. Does your child recognize speech intonation patterns? Preparing the child for meaningful information patterns via Cued Speech is essential pre-training. Rising and falling pitch patterns should occur in the child's own speech if amplification is effective. Checking the child's perception of intonation patterns in any other way is very difficult without specialized training. This is one area where amplification alone may be providing stimuli, but without Cued Speech the child may ignore the hearig available to him/her because it is meaningless.
11. Does your child respond to the varying stress of syllables in a word, phrase, or sentence? Again, correctsyllable stress in the child's speech may be the beest check of amplification benefits. Skilled cuers canshow stress patterns visually to some extent, but the subtle requirements of speech will rely heavily upon adequate amplification.
12. Can the child recognize vocabulary words with amplification alone? First try closed sets of words which are very familiar to the child (names of close relatives, pets, toys, body parts). Ask the child to repeat words from auditory cues alone. Then try less familiar words, but ones which have been cued and established in the receptive vocabulary of the child. A careful analysis of words missed by the child may give you very important information about the limits of amplification. The results may also prompt you to insist that supplementary forms of amplification be available to the child at times when he/she is learning new words.
13. Can the child recognize oral sentences with amplification?Because the child is going to be dealing with what is essentially a non-cueing world, amplification plus speechreading will be critical coping tools throughout life.We know from research studies such as he one done by Gaye Nicholls that early consistent training with Cued Speech significantly improves utilization of residual hearing and speechreading, but the caring parent, teacher, clinician will leave nothing to chance for the individual hearing=impaired child. Frequent checking of a child's ability to deal with oral syntax, morphological changes, and the suprasegmentals of oral language via amplification will provide realistic direction to those responsible for helping the child to develp the best possible receptive and expressive speech skills.
14. Is the child's auditory memory span improved with amplification? Can the child both recognize and retain oral phrases and sentences, strings of digits, lines of poetry and songs? Formal checking without the use of visual cues is relatively simple. What is not so simple is the factoring out of what contributed to the current skills of the child. Does the "credit" go to Cued Speech or to amplification> Who cares -- if the child makes real progress?
The answers to these fourteen questions should provide objective informationabout the current efficacy of amplification for your child. But this is not the place to stop questioning. You need to weigh these factors as well:
1. Was this child wearing a hearing aid? If the answer is "Yes," what type? Body pack, behind the ear, monaural, binaural, monaural Y-cord, digital, processor with cochlear implant?
2. Was the hearing aid functioning appropriately and consistently prior to this hearing evaluation?
3. Is this hearing aid the best possible form of amplification for this child at this time in his/her educational development?How would you rate benefits?4. Is the child exposed to other forms of amplification regularly: group trainer. FM system, individaul desk unit, TV sound turned up loud, Hi-Fi with speakers, Hi-Fi with earphones, amplified telephone, Sony Walkman, etc.?
- Yes, my child is making maximum use of the available aid.
- The aid is obviously of some benefit and should be worn regularly.
- The effectiveness of the aid seems marginal and doubtful, but we'll continue with it for four more weeks.
- The hearing aid is probably of little value to the child and should be abandoned.
5. What is the child's response to other kinds of amplification? Is there something to be learned from these responses, or should such alternate forms of amplification be abandoned?
6. Is there evidence to suspect that the child's hearing with amplification may be improving? Deteriorating? About the same as in prior checks?
7. Would a formal clinical re-evaluation be worthwhile at this time?If so, what type: audiological, medical, psychological, educational, or other?
The Monthly Hearing Evaluation form on the following page is a summary of the questions we have been asking about the efficacy of amplification in auditory training. Feel free to photocopy the form for periodic checks of your child.
Naturally, the age of the child, the amoung of residual hearing available, and the speech/language skills the child has acquired via Cued Speech or other strategies will limit the number of items which you can score with confidence during any given evaluation. However, the scores and the candid answers for the final items on the form over a period of a few months -- NOT YEARS! -- should give you a realistic and pbjective view of the importance of appropriate amplification to your child's speech/language development.