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Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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n
Profound: only loud environmental sounds and noises are available through audition. With
this degree of hearing loss, most communication will require a visual component (e.g., lip
reading, sign language).
There are positive prognostic indicators associated with some of the variables that can influence
speech and language development for a child with hearing loss (Novaes et al., 2012). Some of those
positive prognostic indicators were identified as:
n
Early and appropriate identification of hearing loss and fitting of amplification
n
Device and amplification use for all waking hours
n
Effective intervention services including speech and language therapy from the time of
identification
n
Language and speech learning environments are favorable for auditory development
n
No additional disabilities (other than hearing loss) are present
Effects of Hearing Loss on Speech and Articulation in Children
Speech and articulation production in children can be greatly affected by hearing loss. Typically,
children with congenital, prelingual hearing loss have more speech production errors when compared
to children with postlingual hearing loss (Pratt, 2005). Speech and articulation production in children
can be separated into three different areas:
n
Intelligibility: the degree to which speech is comprehendible or the degree to which speech
can be understood
n
Segmental information: the discrete sounds like consonant and vowel sounds that create
spoken language
n
Suprasegmental information: prosodic information like duration, intensity, and pitch that is
superimposed on top of segmental information (Tye-Murray, 2022)
There is an evidence base that identifies a relationship between speech production and speech
perception in children with hearing loss (Ching et al., 2018). Speech perception issues or lack of
auditory access can create specific deficits in each of the three areas related to speech and articulation
identified previously.
n
Deficits related to intelligibility (Ashori, 2020)
Historically, children with a greater degree of hearing loss or prelingual hearing loss have
poorer speech intelligibility
Great variability noted in this area for children with hearing loss
Advances in technology and more advanced hearing aids, CIs, and assistive technology
systems have aided speech production in children with hearing loss
n
Deficits related to segmental information (Sundström et al., 2018)
Children with hearing loss often demonstrate some developmental speech production errors
and patterns that are typical of younger children acquiring speech.
●
For example, many children demonstrate the phonological speech production pattern of
final consonant deletion (the final sound in a word is deleted or not produced). A child
CHAPTER 4 Communication Across the Lifespan: Typical vs. Disordered
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might produce the word “hat” as “ha” without the final sound. For a child with hearing
loss, the reason that the final consonant is not produced is different than a child without
hearing loss. A child without hearing loss is probably developing speech in a way that is
typical and will most likely begin producing sounds at the ends of words as development
progress continues. However, for a child with hearing loss, the most likely reason they are
not producing sounds at the ends of words is that the child is not perceiving the sound
through audition and, therefore, not producing it. A child with hearing loss is not likely
to “outgrow” developmental speech production errors without appropriate amplification
and intervention.
Common speech deficits with vowels
●
Vowels are typically substituted with another vowel sound or distorted rather than
omitted from speech production
●
Vowels are often neutralized, if distorted
●
Without appropriately fit technology, there is more distortion with vowel production as
the degree of hearing loss increases
Common speech deficits with consonants
●
Consonants that are more visible on the mouth are typically produced more accurately
than consonants that are less visible
●
Characteristics of consonants that are not visible (e.g., voiced and voiceless) are often
produced in error
●
Consonants are often subject to substitutions, omissions, and distortions due to
decreased auditory access. Specifically, many consonant errors for children with hearing
loss are related to a lack of auditory access in the higher-frequency range.
n
Deficits related to suprasegmental information (Higgins et al., 2003)
153
Errors noted in prosodic information include errors in stress, rate, coarticulation, and
breath support
Voice pitch can be high or monotone
Frequent pauses may occur, often at inappropriate semantic and syntactic boundaries
Effects of Hearing Loss on Receptive and
Expressive Language in Children
Issues with receptive and expressive language are often categorized into the three main areas associated
with language: form, content, and use (Turnball & Justice, 2013).
n
Form: syntax and morphology
n
Content: semantics
n
Use: pragmatics
It is important to note that the difficulty with the use of language is most likely related to
decreased auditory access to spoken language and not a true deficit in pragmatic language
ability.
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As with speech production and speech perception, a lack of appropriate access to a language
base can create specific deficits in each of the three areas related to receptive and expressive language.
Explicit deficits are noted in relation to spoken language comprehension and production in children
with hearing loss when compared to typical language development in children (Moeller & Tomblin,
2015; Yoshinaga-Itano et al., 2020).
n
Common deficits in form
Reduced mean length of utterance
Decreased use of complex sentence structures and decreased use of clauses
Overuse of simple sentence structure (e.g., subject-verb-object)
Infrequent use of adverbs, auxiliary verbs, conjunctions
Incorrect word order
Incorrect use of verb tenses
n
Common deficits in content
Reduced vocabulary
Decreased ability to label and sort words
Reduced comprehension of object function
Words are often categorized by things that can be seen
Decreased understanding of figurative language (e.g., idioms)
Difficulty with multiple-meaning words
n
Common deficits in use
Restricted range of communicative intents in preschool kids with hearing loss
Lack of knowledge regarding conversational conventions (e.g., changing topics, closing
conversations)
Limited understanding of communication repair strategies
Effects of Hearing Loss on Literacy in Children
Deficits in receptive and expressive language skills in written language (e.g., reading and writing)
are often similar to the content, form, and use errors of receptive and expressive language in spoken
language for a child with hearing loss. Mapping speech to print (i.e., orthographic mapping) is defined
as the process of moving from a spoken phoneme to a grapheme (i.e., written letter), which progresses
to spelling a spoken word in written form (Wasowicz, 2021). The deficits for children with hearing
loss related to written language can arise from a limited development of an auditory basis for mapping
speech to print. In different terms, a child with hearing loss does not auditorily perceive a sound
correctly and therefore has no basis to learn the written form because of the errored processing of the
spoken form. Limited auditory access due to hearing loss can result in deficits related to reading and
writing such as:
n
Deficits in phonological awareness (i.e., ability to recognize and manipulate the spoken parts
of sentences and words)
n
Deficits in phonemic awareness (i.e., ability to notice and work with the individual sounds in
spoken words)
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n
Writing samples may contain:
155
Form errors such as the omission of articles and bound morphemes (boy vs. boys)
Overuse of subject-verb-object sentences
Lack of narrative structure (e.g., no use of signals in writing to indicate the beginning of
a story)
Effects of Hearing Loss on Psychosocial Development in Children
With the recent advancements in technology and amplification, many children with hearing loss are
provided auditory access that allows them to develop listening, speech, language, and literacy skills
in spoken language that are comparable to children with normal hearing. As discussed previously in
this chapter, pragmatics involves the use of language in changing social situations and develops in a
predicted way for most children that demonstrate typical development patterns. Despite the progress
many children with hearing loss demonstrate in spoken language production and understanding when
provided with appropriately fit technology, many continue to struggle with two specific areas that fall
under the umbrella term of pragmatics: theory of mind (ToM) and psychosocial (e.g., social-emotional)
development (Rall, 2007).
n
ToM is the ability to attribute emotional and mental states to oneself and to others, as well
as understand that others have perceptions that are different from our own. Westby (2017)
differentiated ToM into two separate areas: cognitive and affective.
Cognitive ToM involves the ability to attribute mental states to yourself and others.
Affective ToM involves the ability to recognize emotions in yourself and others.
There are precise deficits in two areas of psychosocial development (i.e., social development and
emotional development) often noted in children with hearing loss.
Specific deficits related to social development include:
n
Few or limited number of friendships that might result in social isolation
n
Difficulty empathizing and issues related to ToM development
n
Feeling intimidated by communication that requires increased social interaction
Lower levels of self-perceived social acceptance
Specific deficits related to emotional development:
n
Decreased semantic repertoire related to emotional development
n
Limited expression of emotional state
n
Decreased accuracy in interpreting emotional states
There are many reasons that a child with hearing loss might have deficits in ToM and psychosocial
development. One explicit reason a child with hearing loss may have difficulty with these skills relates
to exposure. There are specific reasons why exposure to learning opportunities for ToM and psychosocial development might be limited for children with hearing loss (Khodeir et al., 2021).
n
Decreased receptive and expressive language skills impact a person’s ability to process more
complex and abstract language situations. If a child with hearing loss has decreased language
skills, language comprehension that requires metalinguistic processing in situations, like
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perspective-taking (i.e., the ability to understand something from another individual’s point of
view), can be difficult.
n
Lack of opportunity to overhear conversations that do not directly include the child with
hearing loss. This specific lack of opportunity leads to fewer opportunities to hear others share
their perspectives. This lack of opportunity leaves a hefty gap in learning experiences related to
perspective-taking.
n
Decreased exposure to vocabulary related to social-emotional learning due to a communication
partner (e.g., a parent) that attempts to use vocabulary that makes comprehension easier for
the child with hearing loss. Similar to the lack of opportunity for perspective-taking, this lack
of opportunity in learning experiences related to vocabulary for social-emotional learning
creates a barrier for children with hearing loss (Morgan et al., 2014).
It is important to note that Deaf children of Deaf parents do not demonstrate this large difference in
psychosocial development (Polat, 2003).
AUDIOLOGY NUGGET
There are simple, informal ways an audiologist can gain information about a
child’s understanding of the two different areas of ToM, cognitive and affective,
during an evaluation.
n
Cognitive ToM can be assessed through a false-belief task, which
provides information regarding a child’s understanding that other people
can have beliefs about the world that are not true.
Smarties Task (Perner et al., 1987) — create a box with a picture of
“Smarties” candy on top. However, place a pencil inside the box rather
than the candy. Ask the child with hearing loss to predict the contents
of the box that appears as though it holds “Smarties.” The child will
typically reply by saying that the box holds Smarties due to the picture.
Then, the audiologist would open the container to reveal that it
actually contains a pencil. The audiologist could then ask what another
child (who has been waiting outside the room and did not see what
was in the Smarties container) would think the box contained.
n
Affective ToM can be assessed through formal or informal measures that
relate to the identification of emotions.
Brainstorm some common scenarios that a child with hearing loss
might experience that elicit different feelings and ask the child how
they would feel.
●
“Your mom picked you up after school and took you to get ice cream.”
●
“Your classmate colored on your paper.”
●
“Your brother yelled at you.”
●
“Your sister wouldn’t let you have a turn on the swings on the
playground.”
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AUDIOLOGY NUGGET
Recently, two measures of hearing aid use have received significant attention
as predictors of success with hearing aids and language outcomes among the
pediatric population: unaided speech intelligibility index (SII) values (discussed
in Chapter 3) and measures from daily use time (often referred to as auditory
dosage; Wiseman et al., 2023). An unaided SII value of .80 or lower has been
suggested as a cutoff in determining the need for amplification among children
with mild hearing loss (McCreery et al., 2020). The authors found that children
with unaided audibility values at or below .80 were at risk for language delays.
Another measure, referred to as auditory dosage, reflects the intensity and
duration of daily auditory access by weighting a child’s hours of aided hearing
by their aided speech audibility and hours of unaided hearing weighted by their
unaided speech audibility (Wiseman et al., 2023). Both measures are evidence
based and should be considered when fitting children with amplification.
157
Formal Ways to Assess Communication
in Children With Hearing Loss
It is important to frequently assess the communication skills, including listening, speech, language, and
cognition abilities of a child with hearing loss. Assessment of all communication skills can contribute
to a child’s therapeutic intervention plan by determining the need for intervention, developing therapeutic intervention goals, and evaluating the progress of a child’s communication skills.
An interprofessional team is often created to effectively assess all skills that contribute to communication for a child with hearing loss. However, specific members of that interprofessional team are
suited for an in-depth assessment of each area that contributes to communication. Therefore, many
children with hearing loss are assessed in each area below by the following professionals.
n
Listening skills: SLPs and/or audiologists
Any changes or fluctuations in listening skills should be reported to a child’s audiologist.
n
Speech production skills: SLPs
n
Receptive and expressive language skills: SLPs
n
Cognitive and intelligence skills: psychologists
n
Communication skills utilized in a classroom setting: mainstream classroom teachers or
teachers of the deaf
Evaluation of Speech and Language Skills
for Children With Hearing Loss
Many standardized tests for the assessment of speech and language were listed previously in this
chapter. These standardized tests can be utilized as a part of the assessment process when evaluating
the communication skills of a child with hearing loss. However, it is important that the professional
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proceed with caution due to the changes in test administration that might be required, including the
use of sign language. If standard scores are utilized, a cautionary statement must be included in the
assessment report.
n
Informal measures (i.e., nonstandardized measures that are typically flexible and personalized)
are also often used for assessment purposes with children with hearing loss. Many checklists
have been developed specifically for children with hearing loss that can provide helpful
information as standardized tests do not always capture the full spectrum of strengths and
weaknesses as it relates to all areas of speech and language.
n
As the needs for children with hearing loss vary so greatly, so do the number of informal
assessments available to clinicians. It would be impossible to develop an exhaustive list of
informal assessments available; however, Supporting Success for Children with Hearing Loss
has developed a fantastic resource of informal assessments for children with hearing loss and
has been included in the Recommended Readings section of this chapter.
Effects of Hearing Loss in Adults
Just as in children, hearing loss for adults can have vastly different effects on each individual with
hearing loss. For adults, significant hearing loss is typically acquired postlingual (i.e., after the development of language). This means that most adults with hearing loss have attained knowledge and
experience in the world and have speech and language that has developed in a typical manner.
The International Classification of Functioning, Disability, and Health (ICF) system was developed
by the World Health Organization (WHO) and is a framework for measuring health and disability
(Threats, 2006). The ICF includes broad components that help determine the multifaceted interaction between functioning and disability. Although this is not a standardized assessment or system, this
type of classification allows for the specific identification of hearing-related difficulties and how they
affect each person in a vastly different way (Hickson & Scarinci, 2007). Three components of this
system are:
n
Body function and body structure
Example: type and severity of hearing loss
n
Activity limitations — a specific skill deficit
Example: difficulty understanding speech in background noise
n
Participation restrictions — how the activity limitation affects life participation in a broader sense
Example: choosing to not meet a friend for coffee for fear of not being able to understand
the conversation
As each person with hearing loss functions in a variety of environments, there are certain aspects
of a person’s life that affect activity limitations and participation restrictions, which include:
n
Personal factors: pertain to the patient and are highly individualized
Example: age, lifestyle, ethnicity, coping style, attitude, habits, preferences
n
Environmental factors: external to the patient but still highly individualized
Example: physical environment, social environment, culture
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Based on individualized factors and situations, hearing loss has varying effects on communication
in adults. One of the main areas that hearing loss can negatively affect is conversational fluency, or how
smoothly a conversation transpires, in a variety of contexts (Caissie & Tranquilla, 2010). Some negative
effects of hearing loss on conversational fluency include:
n
Disrupted turn taking
n
Modified speaking and listening styles
Communication partners: speak slower, exaggerated/precise articulation
Person with hearing loss: reliance on gestures and facial expressions, unusual gaze patterns
n
Less rich imagery in spoken language from the communication partner
n
Inappropriate topic shifts
n
Superficial content
n
Frequent clarification
n
Violation of implicit social rules
Disrupted grounding: interruption in information exchange when communication partners
do not establish a body of information as shared common knowledge
Bluffing is a maladaptive strategy where the person with hearing loss pretends to understand what
a conversational partner is saying by nodding, smiling, or agreeing. Each person with hearing loss has
different reasons for bluffing and these are often multifaceted. In many situations, bluffing is impacted
by a person’s personality and their acceptance of the hearing loss. The use of bluffing may lead to a
feeling of powerlessness to manage communication breakdowns for the person with hearing loss.
Communication Assessment for an Adult With Hearing Loss
A comprehensive communication assessment for an adult with hearing loss could include a needs assessment (e.g., assessment of the psychosocial impact on a person’s quality of life) and screening measures
for communication, including measures for cognition, speech/language, conversational fluency, and
listening (Heffernan et al., 2016; Vas et al., 2017). Adults with hearing loss have immensely different
needs, which means the goals of the communication assessment may vary for each patient. Some of
the possible goals for a communication assessment might include:
n
Identify activity limitations and participation restrictions in all settings (e.g., home, work)
n
Assess conversational fluency and communication breakdowns
May vary as a function of communication partner and setting
May vary based on the topic of conversation
n
Evaluate the psychosocial impact of hearing loss on everyday activities
n
Assess how effectively they use communication strategies in a variety of settings
Activities Utilized for a Communication Assessment
There are many ways to evaluate the impact hearing loss has on adults’ communication within a
communication needs assessment. Three common tools utilized by audiologists to assess a person’s
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communication, including activity limitations and participation restrictions, are interviews, questionnaires, and unstructured communication interactions. Each tool is listed below, including a description,
advantages, disadvantages, and examples of that tool.
1. Interview
n
Description: clinician asking specific questions of the individual with hearing loss regarding
specific situations
n
Advantages: very specific information obtained regarding the individual
n
Disadvantages: can be time-consuming and difficult specifically for new clinicians with less
experience
n
Examples: What brought you here today? Do you have to ask people to repeat what they said
a lot? If so, tell me about a specific time you asked someone to repeat themselves. Are there
times when you have more trouble hearing, such as in a car, restaurant, theater, or in large
groups? If so, tell me about a specific time you had some trouble hearing.
2. Questionnaires
n
Description: individual answers questions on an assessment scale regarding a variety of factors
(e.g., situations, emotions, strategies) related to hearing loss
n
Advantages: easy to administer for the clinician as the questionnaire is typically just provided
to the patient for completion
n
Disadvantages: specificity can be lacking if the appropriate questionnaire isn’t administered
n
Examples: the Hearing Performance Inventory (HPI; Giolas et al., 1979), the Hearing
Handicap Inventory for Adults (HHIA; Newman et al., 1990), and the Hearing Handicap
Inventory for the Elderly (HHIE; Newman & Weinstein, 1988)
3. Unstructured communication interactions
n
Description: observation of spontaneous communication interactions between the person
with hearing loss and a variety of communication partners
n
Advantages: provides real-world information on how the individual with hearing loss is
communicating with frequent communication partners
n
Disadvantages: may not be possible to observe during the course of a typical audiological
evaluation
n
Example: observing a husband and wife or a parent and an adult child have a conversation
during an audiological evaluation
Conclusions
Communication provides a connection to people and experiences. Deficits in communication hinder
one’s ability to build relationships and participate in life activities. It is important for audiologists to
understand communication development, communication disorders, and strategies utilized to assess
communication across the lifespan. With this understanding, audiologists can apply that knowledge
to communication development and assessment for persons with hearing loss. This knowledge allows
the audiologist to be an effective interprofessional team member and a skillful clinician.
CHAPTER 4 Communication Across the Lifespan: Typical vs. Disordered
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Recommended Readings
161
American Speech-Language-Hearing Association. (n.d.).
How does your child talk? Birth to one year. https://
www.asha.org/public/speech/development/chart/
Kaderavek, J. (2011). Language disorders in children:
Fundamental concepts of assessment and intervention.
Pearson.
McLeod, S., & Baker, E. (2017). Children’s speech: An
evidence-based approach to assessment and intervention. Pearson.
Olusanya, B. O., Davis, A. C., & Hoffman, H. J.
(2019). Hearing loss grades and the International
Classification of Functioning, Disability and
Health. Bulletin of the World Health Organization,
97(10), 725.
Owens, R., & Farinella, K. (2019). Introduction to com-
munication disorders (6th ed.). Pearson.
Owens, R. E. (2020). Language development: An intro-
duction (10th ed.). Pearson.
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