Chatting at the kitchen counter, reading books at bedtime, listening to grandparents’ stories, singing songs with cousins… these are just some of the moments that anchor families and foster connection. What they have in common is that they’re all bound by language—the language of the home.
“Research shows that when children with hearing loss learn to communicate with Listening and Spoken Language [LSL],” says Barbara Hecht, PhD, Clarke’s national director of strategic initiatives and partnerships, “they are likely to experience language-learning success, improved literacy outcomes, enhanced quality of life and above all—a powerful kinship with their loved ones.”
And because roughly 90% of children with hearing loss are born to parents with typical hearing, many families will choose the spoken language of the home as their communication modality.
But how do children who are deaf or hard of hearing get to this point—achieving milestones on par with peers who have typical hearing and enjoying a fulfilling, promising life? It starts with the proper amplification, support from LSL experts and a steady diet of language nutrition.
“Cochlear implants were consistently associated with at or above expected levels of academic achievement in adolescence, with those children receiving CIs at earlier ages demonstrating the highest performance in reading and writing.”
Establishing the Ability to Listen: Identification and Amplification
Children who are deaf or hard of hearing must first be able to access sound to benefit from any language-rich environment.
Ideally, children with hearing loss will meet the 1-3-6 benchmarks, established by EHDI (Early Hearing Detection and Intervention): Screened by one month old, diagnosed by three months old and in an early intervention program by six months old.
As many experts point out—the earlier the better.
No matter the technology path—hearing aids, hearing aids before cochlear implants, cochlear implants, bone-anchored hearing aids (BAHAs)—the sooner children can access sound, the sooner they will be able to learn listening skills.
In a 2023 longitudinal study of 188 children with bilateral severe to profound hearing loss with cochlear implants (CIs) and 340 children with bilateral severe to profound hearing loss without CIs, researchers found that the children with CIs experienced better educational outcomes in reading, writing and—notably—quality of life, compared with the children who did not use CIs. Those who received their CIs before 18 months had the highest levels of spoken language and academic success.
Research out of Australia, known as the LOCHI (Learning from the Longitudinal Outcomes of Children with Hearing Impairment) study, shows that children who receive their cochlear implants before the age of one are primed for LSL success. Per Teresa H. Caraway, PhD, CCC-SLP, LSLS Cert. AVT, CEO of Hearing First in the organization’s 2019 “Mission: Probable” white paper: “We now have compelling empirical evidence that cochlear implantation before 12 months of age and consistent, exclusive use of LSL contribute to better language outcomes for children with hearing loss.”
And a study from the University of Melbourne found that 80% of children who were implanted by their first birthday achieved normal vocabulary development.
For children who are able to access the sounds of spoken language with hearing aids, the outlook is similarly strong. The LOCHI study also found no difference in language outcomes at three years of age for children with cochlear implants versus children with hearing aids.
It’s important to also note that the sooner a child has access to sound and the ability to listen, the sooner they can benefit from incidental learning through overhearing, as overhearing accounts for up to 90% of daily language learning.
With early identification and appropriate amplification in place, children with hearing loss can develop full language and literacy skills. They are on a path to lead independent lives.
Good access to the sounds of spoken language is not all they’ll need, though. With the support of an LSL professional, building a language-rich environment at home will be essential.
"[Children with hearing loss] who received [cochlear] implants before 18 months of age performed at or above age and gender norms for spoken language and academic achievement.”
How to Provide Nourishment through Language—as Early as Possible
Children with hearing loss require consistent language nutrition, or the high-quality conversations, interactions and reading aloud that caregivers engage in with their children—and a lot of it. And since we know that 80-85% of brain development occurs during the first three years of life, it’s important to start providing this nourishment as early as possible.
In fact, in a 2016 review of 103 articles, researchers found that “quantity and quality of talking, interacting and reading with a child in the first three years of life are strongly associated with language and cognitive development as well as school readiness and academic performance.”
High-quality interactions are characterized by complex, open-ended, response-eliciting speech. For example, “Tell me what you want for your birthday,” might elicit a thoughtful, complex response, while “Do you want a train set for your birthday?” could be answered thoroughly with an emphatic head nod.
This is confirmed in the 2016 Outcomes of Children with Hearing Loss (OCHL) study, in which researchers found that children with bilateral, mild-to-severe hearing loss during infancy and their preschool years experienced better language outcomes when their families used open-ended, complex speech. They noted, “It is important that we encourage early intervention practices of coaching caregivers to provide CHH [children who are hard of hearing] with high amounts of quality linguistic input and to adopt an interaction style that is conversational eliciting as opposed to directive.”
“...The most effective method to optimize listening and spoken language outcomes is to emphasize the child’s access to language through audition [hearing].”
Research shows that without individualized coaching and support from an LSL professional, families of children with hearing loss were more likely to use directive language (e.g., “Come here,” “Stop,”) than families whose children have typical hearing. But children who are deaf or hard of hearing have much to gain from open-ended conversations.
Clarke experts’ recommendations for families are customized to each language learner’s skill level and include narration, re-phrasing and paying attention to what interests a child to initiate engaging conversation. For example, if a child seems interested in the dog’s water bowl, start talking about it. Explain that there’s water in it, and it’s wet. Let them touch it. Ask why they think there’s a bowl of water on the floor. How is it different from how they drink water? Why don’t they drink out of bowl? Try not to oversimplify, an easy habit when speaking to children, as language learners benefit greatly from new and different vocabulary. This manner of interaction—with plenty of back and forth, rich with familiar and unfamiliar vocabulary, offering challenges a few steps ahead of the learner—is a building block of learning language and readily available to families in their homes.
Find tips for each phase of language learning at How to Create a Rich Learning Environment at Home—for Children at All Stages on Clarke’s Resources page.
What we Know about Literacy Outcomes and LSL Education
Literacy, more than just reading and writing, also includes the abilities to identify, understand and interpret information in our constantly changing, information-heavy society. Literacy skills allow individuals to achieve educational success, create earning potential, maintain health and connect with peers—among myriad other benefits.
How does LSL education connect to literacy outcomes?
Research demonstrates that early exposure to oral language is an essential foundation for language development and the establishment of literacy skills. In a 2007 paper, Connie Mayer, EdD, MEd, notes, “it is widely accepted that children with a stronger spoken language base are better placed to develop early literacy abilities than those with weaker abilities in this area.”
She offers show-and-tell as example of the language and literacy demands children face as early as kindergarten, where they are encouraged to share their experiences in a somewhat similar fashion to composing a paragraph. They must assume no background knowledge on the part of the listener, include an opening sentence, pare down to the most relevant details and handle syntactical complexities.
She writes, “The implication for deaf children is that early literacy programs must place a premium on the development of face-to-face English.”
For this reason, Paula Gross and Lyn Robertson pointed out in a 2018 publication that “using an LSL approach with children with hearing loss is a promising way of making sure they develop the requisite language capabilities underlying literacy.”
In a 2017 paper titled, “Early Sign Language Exposure and Cochlear Implantation Benefits,” published by the Childhood Development after Cochlear Implantation (CDaCI) initiative, researchers studied the impact of the use of sign language on the development of speech recognition, spoken language development and literacy skills. They found that children whose families did not use sign language exhibited significantly better literacy skills than the families who used it on a short- or long-term basis.
From the paper: “Children without early sign language exposure achieved better speech recognition skills over the first 3 years postimplant and exhibited a statistically significant advantage in spoken language and reading near the end of elementary grades over children exposed to sign language.”
In their follow-up with test subjects during their late elementary years, the research team found that the children with hearing loss whose families did not use sign language demonstrated language skills on par with children with typical hearing. It’s worth noting that the difference in language outcomes here may be connected to the quality—or lack—of LSL support those families who used sign language received, rather than any direct negative effect of using sign language.
With early LSL support and appropriate hearing technology in place, studies show children who are deaf or hard of hearing can develop typical language and literacy skills. For example, from a 2022 study published in the International Journal of Pediatric Otorhinolaryngology, researchers concluded, “Our long-term study showed that with early technical and educational intervention [from LSL specialists] children with HI [hearing impairment] have the potential of developing language fundamentals within normal range. Furthermore, a vast majority of children with HI score high on parameters of social well-being.”
And the academic benefits of a strong foundation in LSL continue well into the school years. In 2021, Connie Mayer and her colleagues examined the reading abilities of children with hearing loss in fourth to twelfth grade mainstream classrooms. These children, who had benefitted from early LSL intervention and hearing technology, obtained scores comparable to scores of students with typical hearing on tests of basic reading and reading comprehension.
An Immediate Challenge: Increasing Access
Right now, the greatest obstacle to families interested in using LSL with their children is accessing the specialists and support they need.
In a 2021 study titled “Access Challenge Index: A Novel Disparity Measure Predictive of Language Outcomes in Children Who Are Deaf/Hard of Hearing,” which set out to study the impact of demographics on language outcomes for children who are deaf or hard of hearing, researchers found that the greatest barrier to these children is access.
Researchers wrote, “Our results suggest that the ability of a D/HH [deaf or hard of hearing] child to access care, which depends on the resources available to the child as well as the support of the child’s family in receiving specialized hearing health care, is the disparity that underlies much of these language outcome differences. This association suggests that of the demographic and clinical factors in this analysis, access to services is the most important factor in predicting a D/HH child’s language development.”
In an effort to increase access for families, Clarke has expanded its tVisit Teleservices Program—virtual LSL services connecting families with teachers of the deaf, speech-language pathologists, early interventionists and more—to include children of all ages and their families. Through tVisits, Clarke is able to offer individualized virtual LSL services to children and their families, particularly those who are unable to access such services in person.
Improving access for families who choose to pursue the language of the home, the language of the heart, remains a top priority at Clarke.
An Education that Leads to Independence: Listening and Spoken Language
Thanks to early detection (with 97% of US infants now receiving newborn hearing screens within the first few weeks of life); advancement of hearing technology (in cochlear implants, hearing aids, as well as remote microphone systems); robust listening and spoken language educational programs and services, children born with any degree of hearing loss now have the potential to achieve age-appropriate language, literacy and quality of life success.
Sources
- Cejas, Ivette et al. “Cochlear Implantation and Educational and Quality-of-Life Outcomes in Adolescence.” JAMA Otolaryngology–Head & Neck Surgery (2023). https://pubmed.ncbi.nlm.nih.gov/37382935/
- Ching, Teresa Y. C. et al. “Learning from the Longitudinal Outcomes of Children with Hearing Impairment (LOCHI) study: summary of 5-year findings and implications.” International Journal of Audiology (2018). https://pubmed.ncbi.nlm.nih.gov/29020839/
- Ching, Teresa Y C et al. “Outcomes of early- and late-identified children at 3 years of age: findings from a prospective population-based study.” Ear and Hearing (2013). https://pubmed.ncbi.nlm.nih.gov/23462376/
- Dettman, Shani Joy et al. “Long-term Communication Outcomes for Children Receiving Cochlear Implants Younger Than 12 Months: A Multicenter Study.” Otology & Neurotology (2016). https://pubmed.ncbi.nlm.nih.gov/26756160/
- Florentine, Michelle M. et al. “Access Challenge Index: A Novel Disparity Measure Predictive of Language Outcomes in Children Who Are Deaf/Hard of Hearing.” Otolaryngology–Head and Neck Surgery (2021). https://pubmed.ncbi.nlm.nih.gov/34488501/
- Geers, Ann E. et al. “Early Sign Language Exposure and Cochlear Implantation Benefits.” Pediatrics (2017). https://pubmed.ncbi.nlm.nih.gov/28759398/
- Gross, Paula and Robertson, Lyn. “Chapter 13: Literacy Growth and Development.” Preparing to Teach, Committing to Learn: An Introduction to Educating Children who are Deaf/Hard of Hearing (2017-2020). https://www.infanthearing.org/ebook-educating-children-dhh/
- Mayer, Connie. “What really matters in the early literacy development of deaf children.” The Journal of Deaf Studies and Deaf Education (2007). https://pubmed.ncbi.nlm.nih.gov/17566067/
- Tomblin, J. Bruce et al. “Outcomes of Children with Hearing Loss.” Ear and Hearing (2015). https://journals.lww.com/ear-hearing/fulltext/2015/11001/outcomes_of_children_with_hearing_loss__data.3.aspx
- Wischmann, Signe et al. “History re-written for children with hearing impairment.” International Journal of Pediatric Otorhinolaryngology (2022). https://pubmed.ncbi.nlm.nih.gov/34856491/
- Wolfe, Jace. “Mission: Probable: Age-Appropriate Listening and Spoken Language Abilities for Children with Hearing Loss.” Hearing First (2019). https://www.hearingfirst.org/mission-probable
- Zauche, Lauren Head et al. “Influence of language nutrition on children’s language and cognitive development: An integrated review.” Early Childhood Research Quarterly (2016). https://psycnet.apa.org/record/2016-29808-031
- “Quick Statistics About Hearing, Balance, & Dizziness.” National Institute on Deafness and Other Communication Disorders (2024). https://www.nidcd.nih.gov/health/statistics/quick-statistics-hearing
1 Comment
Patricia Yacobacci, Ph.D
Excellent article. I trained at Clarke and loved using this knowledge working with children at Callier Speech and Hearing Center and Houston School for Deaf Children. It’s great to “catch up” on current research.