The scope of this Practice Portal page is children ages birth–18 years who are either born deaf or hard of hearing or acquire hearing loss later in childhood. It focuses on language and communication considerations following initial comprehensive audiologic assessment and identification.
For information specific to hearing; hearing screenings/assessments; diagnosis; and related technologies, interventions, and accommodations (e.g., hearing aids, implantable hearing devices, classroom acoustics, interpreters), refer to the Language and Communication of Deaf and Hard of Hearing (DHH) Individuals Evidence Map and relevant Clinical Topics in the Practice Portal.
For discussion of terminology used in this Practice Portal page, see Hearing-Related Topics: Terminology Guidance.
Children who are identified as deaf and hard of hearing (DHH) are diverse. They have differences in their hearing thresholds, ages of identification, medical and educational histories, linguistic backgrounds, and cultural identities. Some children are identified pre- or perilingually (before fully developing language and/or speech); others develop hearing loss or are identified postlingually (after acquiring language and/or speech).
There is no “one size fits all” when discussing language and communication of children who are identified as DHH. DHH children use various languages, communication tools, systems, and technologies. They receive education and support services in a variety of settings and have diverse experiences with DHH peers and adults.
Early exposure and consistent access to a complete language (signed, spoken, both, or other/augmentative and alternative communication [AAC]) are critical for communication development for all children. Role models in a language-rich environment along with early auditory and/or visual access to language using tools (e.g., eyeglasses, hearing technology) to support family-centered goals provide a strong foundation for optimal cognitive, communication, academic, social, and vocational outcomes (Joint Committee on Infant Hearing [JCIH], 2019; Kushalnagar et al., 2010; Loy et al., 2010; Niparko et al., 2010; Tobey et al., 2013).
Child and family/care partner needs, goals, and preferences guide discussions about their desired outcomes and the family-centered supports and services needed to achieve those outcomes. Families may explore multiple languages and communication methods with their child. A child’s best mode of communication (preferred and most effective) may change over time with changes in the child’s needs, communication contexts, and educational settings (National Center for Hearing Assessment and Management, 2018). Audiologists and speech-language pathologists (SLPs) present evidence-based information about all languages, communication tools, and educational programs at the time of identification and as the child develops so that families/care partners can make informed, evidence-based decisions to meet the desired outcomes and dynamic needs of their children as they transition toward adulthood (American Speech-Language-Hearing Association [ASHA], 2013; JCIH, 2019; White, 2018).
Approximately 95% of children identified as DHH are born to hearing parents, into homes where spoken languages are in use at the time of birth (Gallaudet Research Institute [GRI], 2013; Mitchell & Karchmer, 2004, 2005). Less than 5% have two parents who are DHH with native sign language proficiency. Approximately 35% of children in the United States come from homes where languages other than English or American Sign Language (ASL) are used (GRI, 2013; Mitchell & Karchmer, 2004; White, 2018). According to a survey of DHH children and youth, more than half of DHH students received education in spoken language–only environments, 15.2% were taught using sign language only, and 13.3% were taught with both signed and spoken languages (GRI, 2013). Forty percent of DHH children have multiple disabilities that may require more specialized supports and services, such as AAC systems (GRI, 2013; Mitchell & Karchmer, 2006; Roush & Wilson, 2013).
Early Hearing Detection and Intervention (EHDI) newborn hearing screening programs referred 86% of infants identified as DHH for early intervention services. Of those referred, 66.6% enrolled in the recommended early intervention services (Centers for Disease Control and Prevention, 2021). In 2019, approximately 7,985 preschool children (3–5 years old) received special education services with an individualized education program (IEP) for hearing-related services. For school-age children (6–21 years old), 64,102 students received special education services under the Individuals with Disabilities Education Act of 2004 (IDEA) disability category of hearing impairment (see ASHA’s resource on hearing-related topics: terminology guidance). Among those school-age children, 88.6% spent some portion of their school day in a regular education program, whereas 11.5% received education in another environment such as a separate school or residential facility (Office of Special Education Programs, 2021). More than 100 schools and programs designed specifically for DHH students are available across the United States (Laurent Clerc National Deaf Education Center, n.d.-c).
Various federal laws, regulations, and programs impact the education and provision of audiology and speech-language pathology services for children who are identified as DHH.
Some states also have their own legislation or policies that affect services and educational plans for DHH children (e.g., Bill of Rights for Deaf and Hard of Hearing Children).
See Federal/State Laws and Regulations Related to Service Provision for Children Who Are Deaf and Hard of Hearing (DHH) for more information on federal and state legislation.
An interprofessional team approach to family-centered service delivery fosters linguistic and communicative competence in children who are identified as DHH. The Joint Committee on Infant Hearing (JCIH, 2019) describes knowledge, skills, and roles important for audiologists and SLPs as well as other team members. In addition to audiologists, SLPs, and families/care partners, other team members may include, but are not limited to,
The roles and responsibilities of these individuals may be overlapping, complementary, and/or supplementary when collaborating to achieve optimal outcomes depending on the needs of the child. Each individual brings unique education and expertise to the process (ASHA, 2004a, 2004b, 2004c).
See also Supporting Students Who Are Deaf and Hard of Hearing: Shared and Suggested Roles of Educational Audiologists, Teachers of the Deaf and Hard of Hearing, and Speech-Language Pathologists [PDF] from the Educational Audiology Association (2018), ASHA’s other hearing-related Practice Portal pages, and ASHA’s resources on Collaboration and Teaming and Interprofessional Education/Interprofessional Practice (IPE/IPP).
SLPs play a central role in the screening, assessment, and provision of speech, language, literacy, and cognitive-communication services for children who are identified as DHH. Professional roles and activities include clinical and educational services (diagnosis, assessment, planning, and treatment, including family/care partner counseling); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).
Appropriate roles and responsibilities for SLPs include, but are not limited to, the following:
As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs engage in only those aspects of the profession that are within the scope of their professional practice and competence. SLPs who serve this population should be specifically educated and trained to do so using the child and family’s desired language(s) and communication outcomes, collaborating with sign and spoken language interpreters when necessary.
Pediatric and educational audiologists have critical roles in the screening, assessment, diagnosis, treatment, and provision of aural (re)habilitation and support services for children who are identified as DHH. Professional roles and activities in audiology include clinical and educational services (assessment, diagnosis, treatment, and accommodations); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles and responsibilities for audiologists include, but are not limited to, the following:
As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists shall engage in only those aspects of the profession that are within the scope of their professional practice and competence, considering their levels of education, discipline-specific training, and experience. The roles of the audiologist will also be guided by state licensure regulations.
Guiding principles for promoting language, literacy, and communicative competence in DHH children include the following.
Children and families have timely access to high-quality early intervention services. Early identification and intervention are critical for DHH children to develop auditory, language, and speech skills. DHH children can achieve communicative, academic, and social–emotional outcomes that match their cognitive abilities and expected developmental milestones when early intervention and exposure to high-quality, fully accessible language input begin as quickly as possible—ideally between 3 and 6 months of age for those identified at birth (ASHA, 2013; JCIH, 2007, 2019; May-Mederake, 2012; Moeller et al., 2013; National Association of State Directors of Special Education [NASDSE], 2018; Sass-Lehrer, 2016; Tomblin et al., 2014, 2015; Vohr et al., 2012, 2014; White & Muñoz, 2014; Yoshinaga-Itano et al., 2010, 2018). Please see Position Statements from the Joint Committee on Infant Hearing for further information.
Services are family centered and capacity building. Family-centered practices are responsive to each family’s unique circumstances, reflect a family’s preferred outcomes and goals for their child, and emphasize family involvement in planning and decision making (Division for Early Childhood [DEC], 2014; IDEA, 2004). Opportunities for families/care partners to directly participate in services, strengthen existing knowledge and skills, and develop communication abilities enhance child and family outcomes (Costa et al., 2019; Cruz et al., 2013; DEC, 2014; Harrison et al., 2016; Sass-Lehrer, 2016). High levels of family engagement promote successful language development outcomes in children who are identified as DHH (ASHA, 2008; Houston & Bradham, 2011; Meinzen-Derr et al., 2011; Moeller et al., 2013, 2016).
Services are culturally and linguistically responsive. Culturally and linguistically responsive services support the needs, values, beliefs, and customs of children who are identified as DHH and their families/care partners (Bunta et al., 2016; Crowe et al., 2013; Douglas, 2011a, 2011b; Peredo, 2016). Many children come from multilingual families where a range of spoken and/or signed languages are used (Crowe & Cupples, 2020). Some children are fully immersed in Deaf culture, whereas others do not associate with the culture at all—depending on their home environments, preferences, and communication partners (NASDSE, 2018).
Cultural dimensions influence family/care partner decisions about services and supports (see ASHA’s resource on examples of cultural dimensions). Perceptions of disability and/or a culture’s beliefs and traditions may impact decisions to seek interventions or may affect how a family/care partner approaches language and communication. People who identify as part of the Deaf community may view being deaf or hard of hearing as a cultural and linguistic difference rather than a disability. Other cultures may place specific emphasis on spoken languages.
SLPs and audiologists provide information to families/care partners in the language and manner that match their learning style(s) and communication preferences. Assessment by a provider fluent in the language of the home and the child increases the validity and reliability of assessment results (Caesar & Kohler, 2007). Providers work with families, qualified interpreters/translators, deaf professionals, and teachers of English language learners (ELLs) to support their heritage language(s) and acquisition of the academic language for children who are acquiring more than one language. They also collaborate to distinguish language differences that are associated with a multilingual environment from speech/language disorders and identify the language(s)—spoken and/or signed—in which the child will be most proficient for daily communication (ASHA, 2004a, 2004b, 2004c, 2013; Douglas, 2011a, 2015; JCIH, 2019; NASDSE, 2018).
See ASHA’s resource on IDEA Part C: Cultural and Linguistic Diversity and the Practice Portal pages on Bilingual Service Delivery; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness.
Qualified providers who have specialized knowledge and skills working with DHH children deliver comprehensive, coordinated, and team-based services. Families and interdisciplinary providers collaborate to support ongoing successful outcomes for speech, language, literacy, cognitive, and social–emotional development and learning. Providers are trained to educate and counsel DHH children and their families/care partners. Providers are also skilled in assessments, tools, technologies, and strategies that support the development of linguistic/communicative competence. Telepractice may be an option to connect DHH children and their families/care partners with professionals who have the specialized knowledge and skills they need (ASHA, 2004a, 2004c, 2008, 2013; Behl et al., 2017; Galvan et al., 2014; Harrison et al., 2016; JCIH, 2019; Laurent Clerc National Deaf Education Center, n.d.-a; Moeller et al., 2013; Sass-Lehrer, 2016; Stredler-Brown, 2017). Please see ASHA’s Practice Portal page on Telepractice for further information.
Services are individualized, based on the highest quality internal and external evidence available. Children who are born DHH may have different needs than children with postlingual hearing loss, children with unilateral hearing loss and bilateral hearing loss have different needs, and children with cochlear implants also have unique needs (Nussbaum & Scott, 2011). Planning for language and communication development is individualized, systematic, and guided by evidence-based practices. It includes ongoing assessment in the child’s most proficient mode of communication and monitoring using methods validated for DHH children (ASHA, 2013; JCIH, 2019; Laurent Clerc National Deaf Education Center, n.d.-a; Wolfe, 2019). Providers integrate (a) research, (b) professional judgment and expertise, (c) child characteristics, and (d) family strengths, preferences, and values to deliver efficacious services. See ASHA’s Evidence-Based Practice (EBP) webpage for guidance on evidence-based decision making.
Services reflect informed and shared decision making by families/care partners based on the child’s language and communication needs. Families/care partners make decisions over time that impact their child’s linguistic and communicative competence. Professionals support them by providing early access to accurate and up-to-date evidence-based information about all languages, communication tools, technologies, programs, and resources. They also provide comprehensive guidance about developmental milestones, specific interventions, and expected outcomes. Families/care partners weigh this information, assessment results, their child’s strengths and needs, and their own goals for communicating with their child, as well as their values, cultural beliefs, and circumstances, to make decisions (ASHA, 2013; JCIH, 2019; Knoors, 2016; Moeller et al., 2013, 2016; Porter et al., 2018; Scarinci et al., 2018).
For additional information on languages as well as communication tools and systems, see the resource page on Languages and Communication Systems for Deaf and Hard of Hearing Children.
Early and full access to a complete language is essential for optimal language learning. DHH children may have challenges acquiring language and meeting expected milestones because of limited access to language through auditory means or limited access to proficient sign language users (Lederberg et al., 2013). When children do not have opportunities to access language fully and effectively in their daily routines during critical development periods, it can affect linguistic and communicative competence as well as cognitive, speech, social–emotional, and literacy skills (M. L. Hall et al., 2019; Humphries et al., 2016; Moeller et al., 2013). The widely accepted term for these negative effects is “language deprivation” (Glickman et al., 2020; W. C. Hall et al., 2017). A strong language foundation is key to school readiness, academic achievement, and long-term outcomes (Cheng et al., 2019; Ching et al., 2018; Kushalnagar et al., 2010; Laurent Clerc National Deaf Education Center, n.d.-b; Moeller et al., 2016; Tomblin et al., 2015).
For children and families with the goal of listening and spoken language, two actions are essential for children to develop listening and spoken language skills: (1) early fitting of amplification, implantable devices, or other assistive technologies and (2) ongoing monitoring of their effectiveness. Children and families benefit from the earliest possible access to well-fitted hearing technology and alerting devices, per JCIH guidelines. The development of listening and spoken language requires optimal amplification and ongoing audiologic follow-up (ASHA, 2008; Geers & Nicholas, 2013; JCIH, 2019; Laurent Clerc National Deaf Education Center, n.d.-a; May-Mederake, 2012; Moeller et al., 2016; NASDSE, 2018; Nicholas & Geers, 2007; Sininger et al., 2010; Tomblin et al., 2014, 2015). However, it is vital to continue to monitor DHH children’s progress with listening devices, as early amplification and intervention does not guarantee full access to and development of spoken language. Please see ASHA’s Practice Portal pages on Hearing Aids for Children and Cochlear Implants for further information.
Services offer access to support and mentorship from other trained families/care partners and individuals who are identified as DHH. Families benefit from interactions with other families/care partners of DHH children who are trained to provide culturally and linguistically responsive support and guidance. Direct access to hearing families with DHH children and DHH peers and adults with varying hearing levels who communicate in different ways provides language and communication models for children as they grow. These contacts are valuable for self-awareness and social–emotional well-being as well as speech, language, and social communication development (ASHA, 2013; Beal-Alvarez, 2014; Hamilton & Clark, 2020; Henderson et al., 2016; JCIH, 2019; Moeller et al., 2013; NASDSE, 2018; Sass-Lehrer, 2016; White, 2018).
Services are guided by regular monitoring of the child’s and family/care partner’s desired outcomes. All DHH children, regardless of hearing level or type/degree of loss, require consistent and frequent progress monitoring so that developmental progress and status changes are identified and managed quickly. This includes assessment of language (spoken, signed, and/or written) and communication modality (auditory, visual, and/or augmentative), speech (if applicable), cognitive skills, literacy, and social–emotional functioning as well as accommodations where indicated. The goal of structured monitoring at regular intervals is to record functional and participation-based outcomes, identify facilitators or barriers, and make necessary adjustments as indicated to ensure that development is on track, services are timely and delivered with fidelity, and no child or family falls through the cracks (ASHA, 2013; Ching et al., 2018; Daub & Cardy, 2021; JCIH, 2019; Lederberg et al., 2013; Moeller et al., 2013; Moeller & Tomblin, 2015; NASDSE, 2018; Szarkowski et al., 2020).
See the Assessment section of the Language and Communication of Deaf and Hard of Hearing (DHH) Individuals Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspectives.
See relevant Practice Portal pages on specific clinical disorders/practices and other hearing-related topics, such as Augmentative and Alternative Communication, Bilingual Service Delivery, Classroom Acoustics, Cochlear Implants, Early Intervention, Hearing Aids for Children, Resonance Disorders, Spoken Language Disorders, and Written Language Disorders.
Assessment of language and communication of DHH children includes (a) formal and informal methods and (b) interdisciplinary collaboration across settings. Consider the purpose of the assessment, the child’s age, the time of onset and/or identification, and the language(s) and/or communication systems being assessed when selecting assessment tools and approaches (Mann et al., 2014; Pizzo & Chilvers, 2019).
Consistent with the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) framework (WHO, 2001), audiologists and SLPs conduct comprehensive assessments to identify and describe the following (M. L. Hall, 2020; Herman, 2015; JCIH, 2019; NASDSE, 2018; Pizzo & Chilvers, 2019):
See ASHA’s resource on Person-Centered Focus on Function: Hearing Loss in the School-Aged Child [PDF] for examples of assessment data consistent with the ICF framework.
Many states’ early intervention and educational systems have their own assessment protocols that outline assessment components, tools, and procedures as well as expected spoken English and ASL milestones. Some states have centers or offices for the Deaf and Hard of Hearing and schools for the Deaf that offer collaborative consultation and evaluation. Information from multiple sources in different contexts provides the most comprehensive assessment of a child’s strengths and needs to help identify necessary services/supports.
Assess the child’s environments (e.g., home, school, community) for access to communication and learning and to identify potential barriers and necessary accommodations, as applicable. NASDSE (2018) and Spangler and Flexer (2015) indicate consideration of the following:
Consider information across these component domains to develop the most appropriate language and communication goals based on the child’s and family/care partner’s goals as well as on the child’s strengths, functional needs, sensory abilities, language access profile, and exposure to language models in various contexts.
Assessment tools and techniques are culturally, linguistically, and developmentally appropriate and vary based upon the goals of assessment. Assessment results are considered within the context of a child’s foundational experiences, cultural orientation, languages and communication systems, sensory access, educational background, and family/care partner priorities and concerns. In some cases, for DHH children acquiring more than one spoken and/or signed languages, bilingual/multilingual or bimodal/multimodal development is addressed and monitored during service delivery and educational planning (ASHA, 2013; Bradham & Houston, 2015; Douglas, 2015; JCIH, 2019; Pizzo & Chilvers, 2016, 2019).
Audiologists and SLPs are mindful of the following:
Assessment of children who are identified as DHH is a complex process that challenges many traditional methods of evaluating language, literacy, speech, and cognition. DHH children often use a wide variety of languages, communication systems, and/or technologies, which may vary based on context and environment. At least 40% have more complex needs due to co-occurring diagnoses (e.g., cytomegalovirus, intellectual disability, cerebral palsy, autism). This diversity can make it hard to determine which languages/systems to include in assessment, how to evaluate their function, and what tools to use to minimize barriers and increase reliability (Caemmerer et al., 2016; Pizzo & Chilvers, 2019). Other assessment challenges are as follows:
See the Services and Supports section of the Language and Communication of Deaf and Hard of Hearing (DHH) Individuals Evidence Map for pertinent scientific evidence, expert opinion, and client/care partner perspective.
See relevant Practice Portal pages on specific clinical disorders/practices, service delivery models, and other hearing-related topics, such as Augmentative and Alternative Communication, Bilingual Service Delivery, Classroom Acoustics, Cochlear Implants, Early Intervention, Hearing Aids for Children, Resonance Disorders, Spoken Language Disorders, and Written Language Disorders.
Audiologists, SLPs, and related service professionals provide complementary, interrelated, and, at times, overlapping services to help children who are identified as DHH acquire, maintain, reestablish, and/or improve current speech, language, listening, and cognitive-communication skills. Evidence comparing services and supports specifically for DHH children is limited. Some DHH children may benefit from adaptations to evidence-based interventions developed for hearing children.
Service delivery for prelingually DHH children has shifted more toward proactive developmental approaches because of advancements in EHDI systems and technology. Goals, services, and supports emphasize early language intervention across contexts to minimize communication delays and disorders. Programming considers individualized needs as outlined above in the Guiding Principles for Development of Linguistic and Communicative Competence section (ASHA, 2013; JCIH, 2019; Lederberg et al., 2013; Moeller et al., 2016).
Establishing strong language foundations early promotes the development of literacy, cognitive–linguistic, and social skills. The benefits of early intervention can only be sustained when supports continue throughout the school years. If developmental milestones are not being met, timely modifications to language and communication plans may be necessary (JCIH, 2019; Lederberg et al., 2013; Moeller et al., 2013, 2016; NASDSE, 2018).
Children may encounter new difficulties when advancing through school as cognitive, communication, academic, and social demands increase. Continue to monitor language and communication competence to detect these challenges early. Even if children do not require persistent service delivery throughout school, they may need services later as new challenges arise. Audiologists and SLPs encourage families/care partners to seek services when they have any concerns about their child’s progress or hearing status.
The child, their family/care partners, and other professionals working with the child benefit from informational counseling. Topics and issues addressed may include the following:
See ASHA’s Patient Education Handouts—Audiology Information Series for resources that may be helpful during counseling. For more information, see the ASHA Practice Portal pages on Counseling For Professional Service Delivery and Cultural Responsiveness.
Consider referrals for additional counseling by a mental health provider (e.g., school counselor, psychologist), support groups, and other community resources if necessary (Dammeyer et al., 2018; Fitzpatrick et al., 2008; Humphries et al., 2019; Theunissen et al., 2014).
Most DHH children are born to typically hearing families who often have listening and spoken language as a goal (White, 2018). Children who become DHH after acquiring language may already have enough of a listening and spoken language foundation to be successful communicators and learners in an auditory environment given that they receive appropriate supports post-onset of hearing loss (Humphries et al., 2019). With early identification and advances in hearing technology, some children with different hearing levels can now access auditory input and work toward listening, spoken, and written language outcomes consistent with expected developmental milestones (Bowers, 2017; Lederberg et al., 2013, 2019). Effective ongoing audiologic management, consistent use of well-fit and maintained hearing technology, and appropriate family-centered intervention are essential for these outcomes to occur (Costa et al., 2019; Cruz et al., 2013; Moeller et al., 2016; Rosenzweig, 2017; Soman & Nevins, 2018; Tomblin et al., 2014, 2015).
Listening and spoken language development can occur in auditory-only contexts or with multimodal (e.g., visual, tactile) supports (Gibbons & Szarkowski, 2019; Knoors, 2016; Roberts & Hampton, 2018; J. A. Scott & Dostal, 2019). The goal of listening and spoken language development is to ensure auditory access and/or functional listening skills.
The goal of auditory skill development, or auditory training, is to develop a child’s “ability to recognize speech using the auditory signal and to interpret auditory experiences” (Tye-Murray, 2020, p. 102). To facilitate auditory skill development, families/care partners and service providers must first ensure hearing technology function by examining equipment integrity and performing daily listening checks (e.g., Ling Six Sound Check [Ling, 1976]; Low-, Mid-, and High-Frequency (LMH) Test [Madell & Hewitt, 2022]).
Auditory skill development can occur in many contexts. Training for younger children who have not yet fully developed listening and language skills tends to consist of a continuum of skills and may include the following types of activities per Erber (1982):
Erber’s model listed above provides a framework for developing a vast array of auditory skills ranging from turning to sounds in the environment to more complex skills (e.g., comprehending a conversation on television or on a telephone). Informal training can be encouraged in daily routines through strategies such as calling attention to environmental sounds, using acoustic highlighting, or recasting and expansion or extension of language during conversations in the home. When using acoustic highlighting, one uses vocal emphasis to draw attention to a target sound, word, phrase, or grammatical structure (Fickenscher, 2022). Expansion involves repeating an utterance by a child using correct adult syntax and semantics, whereas extension of the child’s utterance adds additional words and information to the child’s utterance (MacIver-Lux et al., 2020). Children can also engage in more formal independent web-based training programs as they grow (Tye-Murray, 2020).
Auditory-Verbal Therapy (AVT) focuses on guiding and coaching families/care partners to be the primary facilitators of their children’s listening and spoken language (LSL) development. AVT emphasizes spoken language acquisition exclusively through listening using hearing technologies such as cochlear implants. Auditory-Verbal Education (AVE) is also part of listening and spoken language training. AVE teaches DHH children to listen and talk exclusively through listening and spoken language instruction and encourages auditory stimulation and mainstream education with peers who have typical hearing as early as possible (AG Bell Academy for Listening and Spoken Language, 2017). The desired outcome of AVT is spoken language through audition, so formal signed systems and speechreading are not directly taught (Estabrooks et al., 2016).
The AG Bell Academy for Listening and Spoken Language (2007) has two sets of principles that outline the practice of AVT and AVE in more detail. See Principles of Certified LSL Specialists.
Professional training and certification in these principles is available for those who serve DHH children primarily using listening and spoken language for communication. Having qualified clinicians with sufficient knowledge and background in this approach is necessary to ensure quality service delivery and functional AVT outcomes.
Auditory-Oral programming also supports family-centered practices to develop LSL skills. However, unlike AVT, it does not teach DHH children to listen and talk exclusively through listening and spoken language instruction. Goals target spoken language development through attention/listening/auditory skills training as well as visual or tactile cues, facial expressions, and natural gestures. A formal signed language or Manually Coded English systems are not utilized because the goal is spoken language (Demers & Bergeron, 2019; Dettman et al., 2013; Thomas & Zwolan, 2019; Tye-Murray, 2020). Families/care partners collaborate with the child’s service providers to carry over strategies and techniques for developing listening, speechreading, spoken language, and cognitive skills in an oral learning environment.
Speechreading addresses speech recognition by integrating auditory and visual information from movements of the face and mouth, as well as supportive gestures (Seal et al., 2013). It differs from lipreading, which relies only on visual cues from the speaker’s face. While lipreading and speechreading programs were historically an important part of Auditory-Oral communication training, advancements in listening technologies and questions about the efficacy of teaching these techniques have led to decreased emphasis on their use in service delivery (Tye-Murray, 2020). Service delivery more often emphasizes communication partner training (e.g., speech rate, prosody, facial characteristics, message complexity/context) and environmental modifications (e.g., sight lines, room acoustics, background noise). However, some DHH individuals also use lipreading and speechreading to support communication exchanges.
Speech recognition abilities influence speech and voice production (Kishon-Rabin et al., 2002). Consider consistency of hearing technology use and its benefit when determining age-appropriate speech targets (Perigoe & Paterson, 2013). Goals often focus on consonant distortions, substitutions, and omissions; phonological processes; and vowel production errors. Common targets may include
Multiple factors impact the approach to articulation and phonological intervention, including age, audibility, stimulability, cognitive–linguistic function, and access to conversational speech models. Self-monitoring spoken language through listening is critical for children to make gains in speech intelligibility at the conversational level (Moeller et al., 2016; Tye-Murray, 2020).
The impact of voice quality on speech intelligibility and social communication is also an important consideration. Some children may not have the auditory access to monitor rate, rhythm, loudness, pitch, intonation, respiration, and resonance of their own speech and voice. Visual, tactile/kinesthetic, and proprioceptive cues can be effective strategies instead. Pairing phonation and articulation goals with these vocal techniques can help improve speech quality and intelligibility (Coelho et al., 2015).
Progress in developing communicative competence using speech is regularly assessed, and ongoing collaboration with audiology is essential to maximize the child’s access to speech information. Consider additional language and communication strategies, technologies, and/or supports if the child is not meeting speech and articulation milestones.
DHH children develop sign language on the same trajectory as hearing children develop spoken language, unless they have a language disorder, lack access to a language-rich environment, or experience a period of language delay or deprivation (M. L. Hall et al., 2019; W. C. Hall et al., 2017). DHH children of deaf parents typically have consistent exposure to language from birth. However, for DHH children of hearing parents, sign language development depends on the age and consistency of quality exposure to a visually accessible first language (Beal-Alvarez, 2014; Marschark et al., 2006; Spencer & Marschark, 2010). Families/care partners require different kinds of supports to provide their children with access to signed language, such as fluent ASL models (e.g., via Deaf mentors, ASL specialists, video narratives) to address manual babbling interactions, early sign vocabulary development, grammatically correct structure, and expression and/or comprehension of more advanced linguistic features (Beal-Alvarez, 2014; Lederberg et al., 2013).
Signed language disorders can exist among DHH children despite early exposure to a signed language, including echolalia, hand/palm orientation errors, and comprehension difficulties (Cripps et al., 2016; Herman et al., 2014; Marshall et al., 2013; Shield et al., 2017; Shield & Meier, 2012; Woll & Morgan, 2012). Additionally, children who experience a period of incomplete language access before gaining access to a signed language often exhibit distinctively disordered characteristics of language deprivation (Cheng et al., 2019; Mayberry & Klunder, 2018). Atypical signed language acquisition and signed language disorders involving aphasia, disfluency, and specific language impairment exist, but there are few evidence-based interventions available. SLPs have reported developing their own intervention strategies such as modeling, correction, and self-reflection to address syntax, semantics, morphology, narrative abilities, use of signing space and nonmanual signals, articulation of signs, and processing of fingerspelling (Quinto-Pozos, 2014; Quinto-Pozos & Cooley, 2020; Quinto-Pozos et al., 2011). Consultation with DHH ASL specialists, when possible, can address these issues using a collaborative approach.
SLPs document children’s receptive and expressive sign language development and target constructs the children do not yet understand or produce. Collaborating with a signed language specialist (e.g., ASL specialist or teacher of the Deaf) is essential if the SLP does not possess the level of sign language proficiency to assess and treat signed language disorders or distinguish a difference from a disorder (Cripps et al., 2016).
Bimodal–bilingual strategies focus on providing children with strong foundations in both signed and spoken languages to promote linguistic and communication access and foster academic success (Chen Pichler et al., 2014; Davidson et al., 2014; Mitchiner, 2015; Mitchiner et al., 2012; Nussbaum, Scott, & Simms, 2012; Swanwick, 2016). Foundations for bimodal–bilingual strategies are developed by
Strategies in a bimodal–bilingual plan reflect individualized child/family/care partner goals and the child’s current level of function and communication preference (Gárate, 2014; Hamilton & Clarke, 2020; Pittman et al., 2016). Goals for communicating in both languages consider the child’s various settings and communication partners, facilitating movement along a receptive and expressive auditory–visual continuum as required (Nussbaum, Waddy-Smith, & Doyle, 2012; Swanwick, 2016).
Other multimodal communication supports may be useful for those not targeting complete bimodal–bilingual language development (e.g., those with multiple disabilities or later onset progressive hearing loss). Supporting spoken language and literacy may involve training children and families/care partners to use one or more of the following systems:
Please see Languages and Communication Systems for Deaf and Hard of Hearing Children for further information.
It is important to provide children and families/care partners with models who use various combined languages and communication systems to help guide acquisition and demonstrate how they might adjust their communication in various contexts (LaSasso et al., 2010; Lenihan & Gardiner-Walsh, 2020; Meinzen-Derr, 2018; Meinzen-Derr et al., 2019; Narr & Cawthon, 2011; NASDSE, 2018; Nussbaum & Scott, 2011; P. V. Paul, 2009; Pittman et al., 2016; Schick, 2011; J. A. Scott & Dostal, 2019; Singer et al., 2020).
See ASHA’s Practice Portal page on Augmentative and Alternative Communication.
Developing literacy skills has been an area of challenge for many DHH children (Easterbrooks & Beal-Alvarez, 2013; Hayes et al., 2014; Lederberg et al., 2013; Marschark et al., 2015; Runnion & Gray, 2019; Wolsey et al., 2018). Children who do not have access to sound and/or use sign language are often learning to read and write a language that differs from their own (i.e., spoken phonological representations of words and print do not correspond to the phonemes of their signs). They may learn to identify words differently from hearing children or DHH children who acquire listening and spoken language skills (e.g., via fingerspelling; Lederberg et al., 2013, 2019).
Regardless of the language(s) used, children who are identified as DHH need constant exposure to reading to promote acquisition of literacy. Print concept knowledge, alphabet knowledge, phonological awareness, and receptive and expressive language skills are critical to prepare children for later conventional reading instruction targeting decoding, fluency, and reading comprehension (Flexer, 2017; Runnion & Gray, 2019). Strategies and programs that have been used to support the process of learning to read and write in this population include the following:
(Flexer, 2017; Gilliver et al., 2016; Hayes et al., 2014; LaSasso et al., 2010; Lederberg et al., 2014; Lund & Douglas, 2016; E. M. Miller et al., 2013; Narr, 2008; Nussbaum, Waddy-Smith, & Doyle, 2012; Runnion & Gray, 2019; Trussell et al., 2018)
(Andrews et al., 2016; Dostal et al., 2017; Gárate, 2014; Lederberg et al., 2019; Nussbaum, Waddy-Smith, & Doyle, 2012; J. A. Scott & Dostal, 2019; Wolsey et al., 2018)
(Albertini et al., 2016; Gárate, 2014; Nussbaum, Waddy-Smith, & Doyle, 2012)
These visual, tactile, kinesthetic, and auditory instructional strategies can be implemented and adjusted according to the needs of each child.
For more information, see ASHA’s Practice Portal page on Written Language Disorders and Hearing First’s Start With the Brain and Connect the Dots: Supporting Children Who Are Deaf or Hard of Hearing to Develop Literacy Through Listening and Spoken Language.
DHH children with autism, intellectual disability, or certain genetic syndromes may have cognitive and social communication difficulties. Even without these diagnoses, DHH children have an elevated risk of developing cognitive and social challenges (e.g., isolation, bullying) due to periods of linguistic and cognitive deprivation and sensory fatigue (Kouwenberg et al., 2012; Warner-Czyz, 2018). Executive function, theory of mind, and social communication appear to correspond with linguistic and communicative competence in children who are identified as DHH. Strategies to support executive function challenges with attention, working memory, and inhibition can help provide the foundation for planning, problem solving, and organization (Knoors & Marschark, 2020; Kronenberger et al., 2014, 2020; McConkey Robbins & Kronenberger, 2021; Szarkowski et al., 2020; Yoshinaga-Itano et al., 2020).
Theory-of-mind training is often addressed in combination with social skills development because both have considerable effects on social interactions and peer relationships (Knoors & Marschark, 2020; Westby, 2017). Skilled services and supports for DHH children tend to focus most on
Some differences in perspective-taking and pragmatic use of language may reflect variations in culturally specific social norms in hearing and Deaf communities, not disordered language (R. Paul et al., 2020).
Various technologies, accommodations, and strategies are available to remove barriers and provide equitable access based on a child’s individual needs. DHH children need full and consistent access to language, communication, and learning across contexts to have the same opportunity to acquire information and participate in activities as their hearing peers. Strategies to address accessibility, visual fatigue, and listening demands throughout a child’s day need to be considered when developing individualized family service plans, Individualized Education Programs (IEP), and 504 plans (Bess et al., 2020; Camarata et al., 2018; Spangler & Flexer, 2015).
Audiologists and SLPs work to promote a child’s self-advocacy with respect to use of these technologies, accommodations, and strategies and monitor their access needs on an ongoing basis in various contexts to make necessary changes (Laurent Clerc National Deaf Education Center & Boston Children’s Hospital, 2015; Spangler & Flexer, 2015; Starr, 2017).
See ASHA’s Practice Portal pages on Classroom Acoustics; Cochlear Implants; Collaborating With Interpreters, Transliterators, and Translators; and Hearing Aids for Children. See also supporting success for children with hearing loss.
When transitioning from early intervention to school-based services, any communication strategies, supports, and technologies the child uses must be documented and monitored to ensure proper implementation and ongoing language development and learning. Please see the JCIH Position Statement (2019, pp. 27–28) and ASHA’s resource on IDEA Part C: Transitions for further information.
Effective transition planning between schools and postsecondary settings is essential to prepare students for academic and vocational success as well as independent living. Some DHH students may have gaps in functional social, communication, and life skills due to challenges with incidental learning and access to language, even if they are on target academically (NASDSE, 2018). Literacy, self-advocacy, reasoning and problem solving, accommodation training, college or career planning/readiness, and independent living skills are important transitional competencies and need to be addressed by families/care partners and professionals with knowledge of the student’s language and communication needs.
Audiologists, SLPs, and other team members can also support development of self-determination and independence by incorporating the following items into their treatment plans:
Services and supports addressing self-advocacy and self-determination facilitate transitions for DHH children, help them to get their needs met, and foster positive language and communication outcomes throughout their lives.
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Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Language and Communication of Deaf and Hard of Hearing Children page:
In addition, ASHA thanks the members of the Ad Hoc Committee, whose work was foundational to the development of this content. Members of the committee were Pam Mason (ex officio), Allan O. Diefendorf (chair), Kathryn L. Beauchaine, Diane L. Sabo, and Anne Marie Tharpe. Roberta B. Aungst, vice president for professional practices in audiology (2004–2006), served as monitoring vice president.
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Language and Communication of Deaf and Hard of Hearing Children [Practice Portal]. Retrieved month, day, year, from www.asha.org/practice-portal/professional-issues/language-communication-deaf-hard-of-hearing-children/.