Chapter 3

Early intervention for children with hearing impairment – a specialist field facing new challenges

 

Learning goals

You are, hopefully, bound to be assisted in your work by a professional who specializes in working with infants and toddlers with hearing impairment.

In this chapter you will learn about key aspects that now make the specialist field of early intervention for children with hearing impairment challenging in new and different ways. The term ‘early intervention’ primarily includes the guidance and ongoing support of families with their children with hearing impairment as well as work with these children in special groups for the hearing impaired from babyhood right up until they start school. A further area that is increasingly growing in importance – and one which this book has particularly in mind – is advising and assisting other caregivers who look after the children on an integrative basis, e.g. as childminders or crèche supervisors. (see also module 4 and 10)

 

1. The children are getting progressively younger

 

For the sake of the child’s overall development, it is crucial that hearing impairment is diagnosed as early as possible. Changes and advances over the last 15 years mean that we are now well on the way towards universal hearing screening for newborns. As a result, the age of the children with whom education professionals and therapists are working is becoming progressively lower. Specifically, this means that children, who are hard of hearing or profoundly deaf, are diagnosed immediately after birth and receive their first hearing aids at around eight weeks, which thus marks the onset of early intervention.

It is therefore becoming increasingly necessary for professionals to acquire detailed knowledge in many areas: early-childhood communicational development, building the parent-child relationship, hearing and speech development, the role of play, and the child’s overall development.

Even in our work with infants under one year of age, individual children and their families are very different and must receive tailor-made help that takes account of these differences.

 

The diagnosis may come in many different ways:

 

• A diagnosis by means of neonatal hearing screening takes the parents completely by surprise
• There is already a child with hearing impairment in the family and the newborn child is also hard of hearing or profoundly deaf;
• The father, mother or both parents are hearing-impaired and their baby has the same diagnosis;
• The diagnosis comes in the wake of an illness (such as meningitis) in the first year of life;
• The diagnosis comes after the child has been given ototoxic drugs (i.e. medication that damages the hearing);
• Premature children weighing under 1,500 grams have an increased risk of hearing impairment;
• Children with other difficulties may, for example, have hearing impairment as part of an overall syndrome;
• Children with ear malformations  that are evident immediately on birth;
• Children whose parents suspect hearing impairment and have their suspicions confirmed during the child’s first year.

 

Within these individual categories, too, we see a very wide range of different situations. If, for example, a sibling child is hearing impaired, many normal-hearing parents (note: 90 % of all parents of children with hearing impairment have normal hearing) find it incomprehensible that fate has dealt them another cruel blow – the birth of another child with hearing impairement -, whereas others may have prepared themselves for the possibility that a further child could be affected. Hard of hearing or deaf parents, too, take the news in very different ways. This depends not least on how well they themselves manage to integrate their own hearing impairment into their everyday lives. Parents of children with auricular (outer ear) malformations and hearing impairment are confronted with the problem immediately after birth and often face months of anxiety as to whether the child might not also have other malformed organs or developmental problems. There are families who have a stable social network, and there are also mothers or fathers who have to cope with the diagnosis – and get on with their daily lives – more or less alone. Many more examples could be given.

However heterogeneous a group of early-intervention children and their families may be, and however differently families deal with the diagnosis of hearing impairment, the initial period with a new baby is a time of tremendous upheaval in any family. The work of an early-years practitioner often involves an outsider coming into the home during a highly sensitive phase, where nothing is as it used to be. The family are still feeling their way with the new arrival, learning to integrate them into their lives and adjust into new daily routines. It is an emotionally charged time for everyone anyway, and then, to cap it all, comes the diagnosis of hearing impairment: “The parents are in a state of emotional turmoil, facing feelings of guilt and a sense of duty, anxiety and grieving, uncertainty and happiness” (Pöllmacher/ Holthaus 2005). Work with infants with hearing impairment thus requires more than specialist knowledge of child development in the first year of life: these professionals also need to provide highly skilled guidance and an empathetic understanding of each family’s individual situation.

 

2. Technical advances

 

New products and techniques are coming on the market at an ever-increasing rate to cover a wide range of needs: auditory diagnostics, hearing aids, cochlear implants, additional equipment (such as FM systems) and apparatus for checking and adjusting these assistive hearing devices. Although the early-intervention specialist does not have to know every technical detail, she needs to keep on top of developments in the technology so that she is, say, able to reflect together with the parents on the input they have received in consultations with doctors, hearing-aid acousticians or at the cochlear implant centre. She must also be able to check that the devices are working properly and advise parents or other caregivers on daily checks and maintenance. (see also module 3)

 

3. The changing role of the early-intervention specialist in parental guidance and support

 

The potential to achieve high level outcomes for children with hearing loss has increased tremendously in recent years due to diagnostic and technological changes. Early intervention programmes for children and their families, which are the key to achieving long-term high quality outcomes, have to embrace this change. The models employed in intervention programmes are a critical factor and it is now a big challenge for professionals to address their role in working with families. Morag Clark describes this challenge in her recently published book on the Natural Auditory Oral Approach: “Observation of programmes around the world shows that professionals often do not act in a way that will really empower parents. This problem seems to arise because of the concept many professionals have about their role in a parent guidance session. Many come into a session with general preset goals, rather than with the desire to focus on observing the parents and then deciding the needs of a specific parent-child relationship at a specific language learning stage.”

The prime target of early intervention in the family must be to empower parents. If the sessions succeed in restoring the parents’ confidence in relating to their child after having been shaken by the diagnosis, then this provides an ideal foundation for auditory language acquisition in everyday life. However, the professional cannot equip parents with this confidence if she talks to and plays only with the child herself to the extent that the parents or other caregivers are relegated to mere onlookers. This may even reinforce any self-doubts, as the parents may end up thinking, “I’ll never be able to relate to my child as well as this professional can!” The early-years practitioner must therefore be able to step back and observe the parents as they interact with their child – and not only how they play or look at picture-books together, but with a big emphasis on everyday activities like emptying the dishwasher, watering a plant or feeding the child. In this way, the professional can make parents aware of their very own individual strengths and tell them which types of interactive behaviour help the child in their development. It is also important to state precisely why such behaviour is valuable for the child at this particular stage of their development. In this way, parents discover that they are well able to provide the right developmental support, even for this child with his/her hearing impairment; to speak to the child in their very own individual style and to raise it in the way they think is right. And, as well as providing feedback on all the positive aspects of the interaction, certain facets of the child’s behaviour can be highlighted. In order that the parents remain confident in their child’s potential for development, it is very important to frequently highlight progress, however modest.

An example to illustrate this: Tim, 20 months old, who wears two cochlear implants, has a piece of paper in his hand that he shows his father. His father says to him: “That belongs in the bin.” The child looks at his father and his expression makes clear that he doesn’t understand what his father has said to him. The father offers the child his hand and says, “Come on, let’s take the paper to the bin.” The child takes his father’s hand and goes with him. Father: “Look, that’s the rubbish bin. Can you open it?” Tim looks at his father and says “Open!” Father: “Yes, open it and throw the paper in.” The father waits; the child does so and says “Closed!” The father praises his son and says: “That’s right, now it’s closed. Well done, you did great!”

Right from the beginning of this short scene, the father does exactly the right thing. He picks up on the child’s non-verbal contribution to communication and speaks to the child. When he realizes the child doesn’t understand, he doesn’t just take the paper from him and throw it away himself but involves him in the action, taking him by the hand. And, all the while, he ‘commentates’ on what is being done. This enables the child to hear the right words in the situation and thus progressively acquire to learn the meaning of the words. The father says what the rubbish bin is called when they are standing in front of it and again tries to stimulate the child’s language development. In this way, he encourages the child to listen. Tim already understands ‘open’ and can (through imitation) say the word. The father then also repeats the child’s utterance and thus endorses the child’s contribution. But he goes one step further: he amplifies what the child says by saying: “Yes, open it and put the paper in.” Then he stops speaking and waits. As already mentioned in Chapter 1, this is of crucial importance for fostering language skills and encouraging dialogue. If the father were to speak continuously in this situation, in order to comment on actions, give instructions or ask questions, this would not help make the child a more attentive listener; on the contrary, they would be overwhelmed with language and would quickly switch off and tune out. However, this pause means the father is giving his son the chance to carry out his action, formulate his own thoughts about it and to express them using language. For example, Tim proudly says “Closed!” The father had not previously mentioned this word. This means that – rather than merely repeating the word after his father (as with “Open!”) – he can already use this word independently and purposefully. He further follows up on this language contribution by his son in a way that, again, serves as validation.

To sum up, the way the father acts in this interaction scene very much serves to foster development. And, at the same time, he helps the child become more independent and his praise boosts the child’s self-confidence. By describing her observations, the professional can give the father a confidence-boost in his communication with his son, even if Tim is only just starting out on his hearing and language development and, for both of them, making themselves understood is not always easy. Obviously, the parents should not be showered with too many feedback points. It is always a good idea to single out just a few items and discuss these in detail. Would Tim’s father benefit from an additional tip? The professional could, say, draw his attention to the fact that praise for Tim would be even more valuable and linguistically useful if he specifies what he is praising, as in: “Great, you can already do that all alone!” or “Great, you can already throw away rubbish without any help!”

 

Whereas it used to be generally the case that the practitioner would bring the child interesting toys and herself encourage the child to listen and speak through play, her role now needs to be understood differently. She is no longer the ‘expert’ who shows the parents what form their child’s help needs to take, and the parents are no longer passive observers who are to copy this behaviour. Rather, the professional brings her experience and knowhow to bear in helping the caregivers relate to the child in their very own way.

In this, it is important that parent guidance is not restricted to play situations but deliberately incorporates the many everyday situations that continually come up. Observing the interaction and then discussing it are thus an integral part of every intervention session. Additionally, the professional herself also interacts with the child, provides ideas to augment the child’s own interests and ideas for play, and gives the parents sufficient time for their questions or to air anything else they want to. Also in the guidance of other caregivers outside the family, this concept offers real individual help because it analyses what parts of the interaction are already supporting the development, and what kind of additional advice is necessary.

An early-years practitioner must, of course, be generally aware of the limits to her own expertise and, as required, refer the parents to other capable professionals such as psychologists, social workers or self-help groups.

 

To close with, here are a few interesting statistics. Bender-Köber/Hochlehnert (2006) show that it can be easily documented that early-intervention sessions – on the grounds of time alone (quite apart from the relationship aspect) can never do the really crucial work in terms of the child’s development.

 

By the time it has reached the age of five, a child will have lived for a total of 43,800 hours, broken down as follows:

Time spent asleep:                           19,800 hours                    = 45.8 %

Time spent awake:                         23,400 hours                     = 54.2 %

in nursery school:                 3,600 hours                     =   8.3 %

in early intervention:              318 hours                      =   0.7 %

in the family :                      19.482 hours                     =  83.3%

The family – and all the other people who help look after the child on a day-to-day basis – hold the key to hearing and language acquisition by children with hearing impairment. It is thus the job of all professionals involved not only to provide the necessary medical and technical support but to offer ongoing individual guidance and assistance so that communication with the child, in everyday life and at play, ‘works’ as well as possible and that, above and beyond this, the child receives the help they need in developing their personality as a whole.