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Waiting to Hear: Requisites for Late-Served Children Across the World

Across all cultures, early amplification and auditory-based therapies are beneficial for families and their children with hearing loss.

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Written By: Ellen A. Rhoades, Ed.S, LSLS Cert AVT & Hilda Furmanski, LSLS Cert AVT

Across all cultures, early amplification and auditory-based therapies are beneficial for families and their children with hearing loss. However, for many reasons, every nation includes children with hearing loss who do not reap the benefits of auditory-based interventions until their preschool years or later. A few of the many reasons may include: (1) the family and/or child has complex issues that involve more than one medical or developmental dysfunction; (2) there are insufficient funds for the family to procure hearing devices; (3) parental opinions that auditory-based interventions will not help until after hearing aids are procured and/or cochlear implantation surgery is completed; (4) some cochlear implant centers may not have established clear cut guidelines for amplification or intervention services prior to surgery; (5) the nation’s health system has yet to formally address the provision of effective hearing devices and early intervention services for children with hearing loss; and (6) late referrals from various service providers.

Hearing loss that is not appropriately treated adversely affects young children’s spoken language, often more so if treatment is not initiated until after the first two to three years of life. Delays in the acquisition of spoken language can negatively influence each child’s sense of belonging and future developmental outcomes. And yet, prior to 1985, many late-identified children with significant congenital bilateral deafness learned to listen and communicate well in their family’s spoken language.  While Universal Newborn Hearing Screening (UNHS) has been introduced in several countries, infant screening has not been implemented widely in many more countries. Consequently, it is imperative that all practitioners and caregivers become knowledgeable about what can be done to ameliorate the devastating long-term effects of hearing loss — perhaps more so for late-identified and late-amplified children and their families.

Just as there are seven letters in the English word “waiting,” there are seven wonderful requisite strategies that caregivers of children need to embrace as soon as hearing loss is diagnosed. The seven strategies are as follows:

Strategy #1 – Accessing the Knowledge Base

The necessity of providing informational counseling to caregivers of children with hearing loss must be recognized by all medical and audiological service providers, including those who will provide and/or program hearing aids and cochlear implant processors (Glade et al., 2018). As provided by auditory-based practitioners, informational counseling involves learning about hearing loss and hearing-related issues, including audiograms and audiological testing (Davidson et al, 2019; Rhoades & Flexer, 2017; Wenrich et al, 2017). It is essential that service providers strongly urge the acquisition of this minimal knowledge base as soon as a child’s hearing loss is diagnosed. With the mandate of seeking auditory-based practitioners for informational counseling, caregivers will more likely take a proactive stance.

Strategy #2 – Speaking Within Earshot

When caregivers learn about hearing-related issues, they will come to understand the critical constructs of “residual hearing” and “reduced range of audibility” (Na et al., 2020; McCreery et al., 2015). They will also learn that most children with hearing loss have some hearing that can be developed into listening skills (Ross, 2006; Walker et al., 2020). Caregivers can then be taught to take advantage of their child’s “Swiss cheese” hearing by speaking to their child “within earshot.” This means that caregivers get within 6 inches or 15.5 centimeters from each child’s ear (Anderson, 2015; Rhoades, 2011). The more they take advantage of children’s limited access to sound, the more quickly they will prime their child to effectively listen with their hearing devices.

Strategy #3 – Learning to Listen

Caregivers will learn how to have their child rapidly respond to sound; this will strengthen audiological testing and programming of hearing devices. They will understand the need for sound conditioning activities and why it is essential to train their child to drop items in a receptacle upon hearing a drum or a particular speech sound (Nakeva von Mentzer et al., 2014; Rhoades, 2011). Caregivers can also learn how to prime their child for good speech by pointing to their ears when certain vowel and consonant sounds are enhanced (Rhoades et al., 2016). More importantly, caregivers will develop and strengthen their child’s auditory attention – a predictor of speech and language development (Wang et al., 2020).

Strategy #4 – Talking Through the Here-and-Now Routines

Caregivers will learn about the importance of shared routines-based activities and why chaotic households do not promote rapid language learning (Bergelson & Aslin, 2017; Hughes-Scholes & Gavidia-Payne, 2016; Rhoades, 2017). They will come to understand the necessity of talking to their child while engaged in the household routines of eating, dressing, toileting, playing, and getting ready for bed. By interacting with their child in the common daily routines of living, caregivers will enable them to figure out the meaning of spoken language. Restated, caregivers will help their child develop a broader knowledge base of word meaning (Rodd, 2020; Silvey et al., 2015).

Strategy #5 – Having Conversational Duets

Caregivers will learn that engaging their child in ”back and forth” games, songs, and non-verbal turn-taking activities can prime them for longer attention spans as well as improve their social and emotional growth, especially since social interactions reflect the true purpose of spoken language (Borrie et al, 2019; Sabic et al., 2020; Wang et al., 2018). Children who are “languageless” benefit from face-to-face communicative events that make them smile and laugh. For example, playing that classic turn-taking game of hiding a coin in “Which hand?” can create a happy conversational duet that, in turn, will likely cause them to eventually vocalize.

Strategy #6 – Getting Physical

Caregivers will learn about the importance of body-based language and how physical activities and rhythmic games promote rapid language learning (Chen et al., 2008; Cirelli et al., 2018; Phillips-Silver & Trainor, 2005). Saying the appropriate action words while moving up and down, dancing slow and fast as well as jumping and hopping ensure that those action verbs are interesting. In turn, this helps children learn the meaning of action words which are much more important than just naming objects.

Strategy #7 – Exaggerating the Prosody  

Auditory-based practitioners diligently inform caregivers about the importance of exaggerating prosody (patterns of rhythm and sound) while engaged in turn-taking verbal exchanges with their child. These exaggerations ensure that most children with residual hearing will be in a much better position to hear the intonational and rhythmic patterns as well as stress or inflection of their home language (Hirsh-Pasek & Golinkoff, 2019; Wenrich et al., 2017). Prolonging the pauses between phrases and sentences as well as exaggerating the prosodic elements in their own speech render greater ease in hearing among language-learning children with hearing loss. In turn, caregivers will enable their child to adapt much more quickly to hearing with cochlear implants and to become independent learners.

Anticipating the Future

Age of acoustic accessibility is not necessarily the primary factor in long-term outcomes (Marschark et al., 2019; Pimperton et al., 2017). The child’s age should not dissuade parents, physicians, audiologists, or other practitioners from commencing auditory-based intervention services. As soon as caregivers learn these “Waiting to Hear Strategies,” they can begin implementing them at home – even before their child begins using any kind of hearing device. Most children with hearing loss will benefit from these strategies.

Implementing these ”waiting to hear strategies” can prime families for activating “a state of readiness” that in turn enables their child to be truly ready for good listening as soon as they are provided with hearing aids and/or cochlear implants. Simultaneously, caregivers will have attained a level of comfort in using listening and spoken language strategies. The more formal auditory-based intervention services can then continue uninterrupted. That is, caregivers must be immediately provided with this knowledge base while their child is “waiting to hear.” When practitioners immediately begin informational counseling, the stage is set for more rapid growth of listening and spoken language; indeed, most children with hearing loss can become listeners even BEFORE receiving their hearing devices.

In addition to imparting this minimal knowledge base to caregivers, it is important that practitioners across all nations establish Hearing Aid Banks. When children undergo cochlear implant surgery, physicians and audiologists can urge caregivers to donate their child’s hearing aids to community-based Hearing Aid Banks. In that way, the children of resource-constrained families will have the opportunity to hear more sounds sooner rather than later. This in turn would promote the listening and spoken language growth of children as well as provide parents with more positive feedback, reduction of stressors, and greater family support.

The final point is that all involved service providers should require that caregivers of children with hearing loss take immediate steps to receive informational counseling from auditory-based practitioners (Bellon-Harn et al., 2019; Leung & Suskind, 2020; Luterman, 2020). Those service providers include persons and groups who sell hearing devices or cochlear implants as well as audiologists and physicians, including cochlear implant surgeons. On the other hand, all auditory-based practitioners should be prepared to immediately initiate the informational counseling process for caregivers of children with hearing loss. Waiting to transmit a knowledge base to caregivers until after each child is fitted with a hearing device is too late.


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A la espera de oír: requisitos de los niños que reciben servicios tardíos en todo el mundo

En todas las culturas, la amplificación temprana y las terapias basadas en la audición son beneficiosas para las familias y sus hijos con pérdida auditiva. No obstante, por numerosas razones, en todos los países existen niños con pérdida auditiva que no reciben los beneficios de las intervenciones auditivas hasta la etapa preescolar o posteriormente. Entre estas razones se encuentran: (1) la familia y/o el niño tienen problemas complejos que implican más de una disfunción médica o del desarrollo; (2) no se disponen de recursos suficientes para que la familia adquiera dispositivos auditivos; (3) los progenitores consideran que las intervenciones auditivas no serán útiles hasta que no se adquieran audífonos y/o se realice la cirugía de implantación coclear; (4) es posible que algunos centros de implantes cocleares no tengan establecidas directrices claras con respecto a los servicios de amplificación o intervención antes de la cirugía; (5) en el sistema de salud del país todavía no se han abordado formalmente la provisión de dispositivos auditivos eficaces y la prestación de servicios de intervención temprana para niños con pérdida auditiva; y (6) derivaciones tardías por parte de varios proveedores de servicios.

La pérdida auditiva que no se trata adecuadamente afecta negativamente al lenguaje hablado de los niños pequeños y, con frecuencia, en mayor medida si el tratamiento no se inicia hasta después de los primeros dos o tres años de vida. Los retrasos en la adquisición del lenguaje hablado pueden influir negativamente en el sentido de pertenencia de los niños y en los resultados futuros del desarrollo. Y, sin embargo, antes de 1985, muchos niños con una sordera congénita bilateral importante que se identificó tardíamente aprendieron a escuchar y a comunicarse bien en el idioma hablado de su familia. Si bien el cribado auditivo neonatal se realiza en varios países, el cribado infantil no se ha implementado ampliamente en muchos países. En consecuencia, es esencial que todos los médicos y cuidadores conozcan lo que se puede hacer para mejorar los efectos devastadores a largo plazo de la pérdida auditiva, especialmente en el caso de los niños a los que se identifica y se facilita amplificación de forma tardía y de sus familias.

A continuación se ofrecen siete valiosas estrategias necesarias que los cuidadores de niños deben adoptar tan pronto como se diagnostique una pérdida auditiva. Las estrategias son las siguientes:

Estrategia n.º 1: acceso a la base de conocimientos

La necesidad de facilitar asesoramiento informativo a los cuidadores de niños con una pérdida auditiva debe ser reconocida por todos los proveedores de servicios médicos y audiológicos, incluidos aquellos que proporcionen y/o programen audífonos y procesadores de implantes cocleares (Glade et al., 2018). Tal como lo facilitan los profesionales de la audición, el asesoramiento informativo implica un conocimiento acerca de la pérdida auditiva y los problemas relacionados con la audición, incluidos los audiogramas y las pruebas audiológicas (Davidson et al, 2019; Rhoades y Flexer, 2017; Wenrich et al, 2017). Es esencial que los proveedores de servicios recomienden con firmeza la adquisición de esta base de conocimientos mínima tan pronto como se diagnostique la pérdida auditiva de un niño. Con la indicación de que localicen profesionales de la audición que les faciliten un asesoramiento informativo, es probable que los cuidadores adopten una postura proactiva.

Estrategia n.º 2: hablar al oído

Cuando los cuidadores adquieren conocimientos sobre los problemas relacionados con la audición, entienden los constructos críticos de la «audición residual» y el «rango reducido de audibilidad» (Na et al., 2020; McCreery et al., 2015). Aprenden también que la mayoría de los niños con pérdida auditiva conserva alguna audición que se puede desarrollar y convertir en habilidades auditivas (Ross, 2006; Walker et al., 2020). A continuación, se puede enseñar a los cuidadores a que aprovechen esta audición residual de su hijo hablándole al oído, es decir, a una distancia de 15,5 centímetros (Anderson, 2015; Rhoades, 2011). Cuanto más se aproveche el acceso limitado del niño al sonido, mayor será la preparación que obtenga para escuchar de una manera eficaz con sus dispositivos auditivos.

Estrategia n.º 3: aprender a escuchar

Los cuidadores aprenderán la manera de conseguir que su hijo responda con rapidez al sonido, lo que reforzará las pruebas audiológicas y la programación de los dispositivos auditivos. Entenderán la necesidad de realizar actividades de acondicionamiento del sonido y la razón de que sea esencial entrenar a su hijo para que deje caer objetos en un recipiente al escuchar un tambor o un sonido concreto del habla (Nakeva von Mentzer et al., 2014; Rhoades, 2011). Los cuidadores pueden también aprender a preparar a su hijo para que hable bien apuntando a sus oídos cuando determinados sonidos vocales y consonantes se resalten (Rhoades et al., 2016). Más importante aún, los cuidadores desarrollarán y fortalecerán la atención auditiva del niño, un predictor del desarrollo del habla y el lenguaje (Wang et al., 2020).

Estrategia n.° 4: hablar a través de las rutinas del aquí y ahora

Los cuidadores conocerán la importancia de las actividades basadas en rutinas compartidas y la razón de que en los hogares caóticos no se fomente el aprendizaje rápido del idioma (Bergelson y Assin, 2017; Hughes-Scholes y Gavidia-Payne, 2016; Rhoades, 2017). Podrán entender la necesidad de hablar con su hijo mientras realicen las rutinas domésticas de comer, vestirse, asearse, jugar y prepararse para ir a dormir. Al interactuar con su hijo en las rutinas diarias comunes de la vida, los cuidadores le permitirán averiguar el significado del lenguaje hablado. Es decir, los cuidadores ayudarán a su hijo a que desarrolle una base de conocimientos más amplia sobre el significado de las palabras (Rodd, 2020; Silvey et al., 2015).

Estrategia n.° 5: mantener duetos conversacionales

Los cuidadores conocerán que la participación de su hijo en juegos, canciones y actividades de turnos no verbales «de ida y vuelta» les puede preparar para mantener la atención durante más tiempo y mejorar su crecimiento social y emocional, especialmente porque las interacciones sociales reflejan el verdadero propósito del lenguaje hablado (Borrie et al., 2019; Sabic et al., 2020; Wang et al., 2018). Los niños «sin lenguaje» se benefician de los eventos comunicativos cara a cara que les hacen sonreír y reír. Por ejemplo, jugar al clásico juego de esconder una moneda por turnos «¿En qué mano esta?» puede crear un feliz dueto conversacional que, a su vez, puede propiciar que finalmente el niño vocalice.

Estrategia n.º 6: realización de actividades físicas

Los cuidadores aprenderán la importancia del lenguaje corporal y cómo las actividades físicas y los juegos rítmicos fomentan el aprendizaje rápido del lenguaje (Chen et al., 2008; Cirelli et al., 2018; Phillips-Silver y Trainor, 2005). Emitir las palabras de acción apropiadas mientras se realizan movimientos hacia arriba y hacia abajo, se baila lento y rápido, o se salta y brinca, propicia que estos verbos de acción adquieran interés. A su vez, esta estrategia ayuda a los niños a aprender el significado de las palabras de acción, que son mucho más importantes que simplemente nombrar objetos.

Estrategia n.° 7: exagerar la prosodia 

Los profesionales de la audición suelen indicar a los cuidadores la importancia de exagerar la prosodia (patrones de ritmo y sonido) mientras realizan intercambios verbales con el niño. Con estas exageraciones se propicia que la mayoría de los niños con audición residual se encuentre en una posición mucho mejor para oír los patrones de entonación y rítmicos, así como el énfasis o la inflexión de su idioma materno (Hirsh-Pasek y Golinkoff, 2019; Wenrich et al., 2017). La prolongación de las pausas entre frases y oraciones, así como la exageración de los elementos prosódicos en su propio habla, facilita la audición de los niños con pérdida auditiva que aprenden un idioma. A su vez, los cuidadores fomentarán que el niño se adapte con más rapidez a la audición con implantes cocleares y se convierta en un aprendiz independiente.

Anticipando el futuro

La edad de la accesibilidad acústica no es necesariamente el factor principal en los resultados a largo plazo  (Marschark et al., 2019; Pimperton et al., 2017). La edad del niño no debe disuadir a los padres, médicos, audiólogos u otros profesionales de iniciar servicios de intervención auditiva. Tan pronto como los cuidadores aprendan estas «Estrategias a la espera de oír», pueden comenzar a implementarlas en el hogar, incluso antes de que su hijo comience a utilizar cualquier tipo de dispositivo auditivo. A la mayoría de los niños con una pérdida auditiva le resultarán beneficiosas estas estrategias.

La implementación de estas «estrategias a la espera de oír» puede preparar a las familias para activar «un estado de preparación» que, a su vez, permite que el niño se encuentre realmente listo para una buena escucha tan pronto como se le faciliten audífonos y/o implantes cocleares. Al mismo tiempo, los cuidadores habrán alcanzado un nivel de comodidad en el uso de estrategias de escucha y lenguaje hablado. A continuación, los servicios de intervención auditiva más formales podrán continuar sin interrupciones. Es decir, los cuidadores deben recibir inmediatamente esta base de conocimientos mientras su hijo se encuentre «a la espera de oír». Cuando los profesionales inician de inmediato el asesoramiento informativo, se prepara el escenario para un desarrollo más rápido de la escucha y el lenguaje hablado; de hecho, la mayoría de los niños con una pérdida auditiva se puede convertir en oyente incluso ANTES de recibir sus dispositivos auditivos.

Además de impartir esta base mínima de conocimientos a los cuidadores, es importante que los profesionales de todos los países creen Bancos de audífonos. Cuando los niños se someten a una cirugía de implante coclear, los médicos y audiólogos pueden recomendar a los cuidadores que donen los audífonos de sus hijos a los Bancos de audífonos comunitarios. De esta manera, los niños de familias con recursos limitados tendrán la oportunidad de escuchar más sonidos con una mayor antelación, lo que, a su vez, fomentará su desarrollo de la escucha y el lenguaje hablado, además de facilitar a los padres una respuesta más positiva, una reducción de los factores estresantes y un mayor apoyo familiar.

El último punto es que todos los proveedores de servicios implicados deben indicar a los cuidadores de niños con una pérdida auditiva que adopten medidas inmediatas para recibir asesoramiento informativo de profesionales de la audición (Bellon-Harn et al., 2019; Leung y Suskind, 2020; Luterman, 2020). En estos proveedores de servicios se incluyen los grupos y personas que venden dispositivos auditivos o implantes cocleares, y los audiólogos y médicos, entre ellos los cirujanos de implantes cocleares. Por otro lado, todos los profesionales de la audición deben estar preparados para iniciar de inmediato el proceso de asesoramiento informativo a los cuidadores de niños con una pérdida auditiva. La espera para transmitir una base de conocimientos a los cuidadores hasta que el niño esté equipado con un dispositivo auditivo puede ser un periodo demasiado prolongado.

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    Take your Listening and Spoken Language Specialist (LSLS®) certification exam for less!

  • Event Discounts

    Discounted registration to AG Bell’s symposium and other events, plus special discounts on travel, restaurants, retail shops and more

  • LSL Professional Directory

    Get listed and found by families that need your services and students that want your mentorship

  • LSL Leading Edge

    An exclusive e-newsletter for AG Bell professional members packed with the latest news and developments in hearing health and the listening & spoken language field

  • Volta Voices 

    AG Bell’s award-winning, quarterly digital magazine in English and Spanish

  • Access to AG Bell’s Network

    Connect with 40+ state chapters located throughout the United States and Puerto Rico

  • Professional Opportunities

    Get involved in AG Bell through committees, task forces, councils and other venues for members to interact and contribute meaningfully

  • The Volta Review 

    Stay current with the latest research through our peer-reviewed, online professional research journal

Seeking membership as a friend or family member?

Membership is always free for family & friends of people who are deaf or hard of hearing and helps connect individuals to our professional community!