CSD 5400 REHABILITATION PROCEDURES FOR THE HARD OF HEARING Language and Speech of Deaf and Hard-of-Hearing Characteristics and Concerns Speech Development

Some Preliminary Remarks The first intelligible word usually occurs at 1 year Discrimination of important phonetic contrasts occur much earlier (receptive) Normal speech development occurs concurrently with language development Consistent exposure to conversations with adults is necessary Normal hearing is necessary Altho a child’s first intelligible words don’t occur until about 12 months of age, infants are born able to discriminate the important phonetic contrasts of the world’s languages Recall the categorical perception studies of the 1970s and 1980s that demonstrated newborns able to categorically perceive important phonetic contrasts like voice onset times (able to differentiate a voiceless from a voiced stop consonant, for example) at birth. Normal hearing allows for this speech discrimination ability, which ultimately is reflected in speech development and production. Remember that speech development occurs concurrently with receptive language development. What happens when HL is present at birth. Well, it’s clear that the development of speech sounds and other expressive language characteristics will be affected to some degree. Lots of variables affect how much speech will be affected. The two major variables appear to be degree of HL (more severe the HL, the more speech is affected) and age of identification/remediation (early id, better speech characterisitics later on) In fact there are some reports to suggest that children ident by 6 months had normal speech by age 5--recall some of the deaf kids in oral programs shown in “Sound and Fury” First we will review normally hearing speech development characteristics and then talk about hard-of-hearing/deaf kids

Newborns Primary form of communication is through their cry Newborns and young infants--birth to 6 mo A newborn’s primary way of communicating is thru it’s cry. While crying can seem foreign and overwhelming at first, parents soon learn to distinguish different kinds of cries for the different purposes they serve.

Newborn Communication Communication intents though crying: Pain or discomfort Hunger Overload Baby’s cries generally indicate that something is wrong--hungry, wet, cold, tired, lonely. Soon, parent will be able to recognize which need their baby is expressing and respond accordingly. Babies also cry when he is overwhelmed by overstimulation of sight and sound. Sometimes they cry for no apparent reason. Crying can be a way of shutting down, if they are overloaded. Believe it or not, infants reorganize themselves (reset, if you will) by a good cry.

Newborn Speech Skills Primarily reflexive sounds at birth Oral reflexes Crying Status of Speech Skills: At birth, babies produce predominantly reflexive sounds (gulping, breathing with vocalization, smacking during feeding, etc) Newborns have a number of oral reflexes--like the rooting one, but also gagging that may also be associated with vocalizations. Crying--very early on, cry during both inhalation and exhalation. Quickly moves to just crying during exhalation--which is what we do during the production of speech sounds.

Changes in Speech Increased development and use of non-distress sounds Some productions of vowel sounds and back consonants /g/ and /k/ By 3 months, vocalization in response to caregiver’s vocalizations Changes in speech Increased development and use of nondistress sounds--cooing some productions of vowel sounds and back consonants /g/ and /k/ by 3 mo, infants will vocalize in response to other vocalizations

Babbling Emerges at around 4 months Random sound play Extremely important landmark of infant development Single syllable units of CV or VC construction At around 4 months--babbling emerges. Babbling is random sound play and becomes more complex as the child gets older. It is an extremely important landmark of infant development. You can imagine babbling as the raw data from which language emerges. At four months, babbling usually consists of single syllable units of CV or VC construction. What you also will hear is changes in pitch and intonation and tone similar to language. As the babbling progresses with age, English syllable structure is also imitated.

Changes in Speech By 6 months, see evidence of more complex sound combinations Labial sounds like /m/ and /p/ are produced more often Stop consonants (p,t,b,k,g,d), nasal consonants (m, n, ing) and vowels comprise about 80% of sounds produced Evidence of reduplicated babbling Emergence of imitative behavior As the child approaches 6 mo, the produce increasingly more complex phonemic combinations. Labial sounds like /m/ and /p/ are produced (babbled) more frequently. Staps, nasals, vowels comprise about 80% of the consonants produced. Also at this time, infants demonstrate reduplicated babbling, which contains long strings of CV syllable repetitions or self-imitations. They may practice this for long periods of time, but attach no real meaning to these sounds. Babies will start to imitate caregivers speech productions including individual speech sounds, pitch, and intonation.

In Summary… By six months, most babies: Make a lot of different sounds React appropriately to different voices Turn and look for sounds Babble with purpose Respond to their name Try to imitate sounds and vocalizations In summary then, by age 6 mo, most babies make lots of different sounds. They laugh, gurgle, coo with familiar people. The react appropriately to loud, angry and friendly voices. They turn and look to novel sounds. They babble for attention. They can respond to their own name--they recognize it They frequently use syllables ba, da, ka, and others they pay attention to their own vocalizations and those of others. They try to imitate sounds and vocalizations.

Landmarks in Speech Development by One Year The use of one or more words with meaning Typical first words include “mama”, “dada”, other nouns important in the child’s life Concept words come next Babbling development gets the child to this point Speech development and landmarks at this time: By the end of the first year, a 1 year old child will use one or more words WITH MEANING—and this is the really important point. A word—not necessarily the “right” one will be used by the child to signify an object—usually the first words represent nouns “mama” and “dada” are common first words. Other nouns used—names of pets, cup or bottle, juice, milk, name of favorite toy or tv character (Barney) Soon, words representing basic concepts are included: come, go bye-bye, go outside, eat, etc.. Getting to this point, tho, is a continuation of babbling development

Stages of Babbling During this Time Echolalia--imitation Varigated babbling--syllables aren’t identical Jargon Phonetically consistent forms Representation Stages and kinds of babbling/speech behaviors: Echolalia—imitation of another speaker’s utterances. At first, babies will/can only imitate sounds or strings they have already produced spontaneously. At this time, tho, they can imitate structures they haven’t spontaneously produced yet. This use of imitation helps them to expand and modify their speech repertoire Varigated babbling—adjacent and successive syllables aren’t identical. Ie pada instead of papa Evidence of jargon—long strings of speech sounds (not meaningful) but with adult-like intonation and pitch. Basically, this is babbling that sounds like real speech. And finally, at the conclusion of this time, the baby develops Phonetically consistent forms (PCFs) which function as “Words” for the infant. They usually approximate the correct English word and parents will help shape that approximation—but at this point the child has illustrated Representation. This is the process of having one thing stand for another. Learning to represent and to symbolize is VERY Strongly related to cognitive abilities.

Affect of Hearing Loss on Early Speech Development and Behavior The effects of hearing loss on speech development are very subtle Generally, even subtle differences sometimes aren’t apparent until after the first birthday Emergence of canonical babbling is a major clue Presence of HL doesn’t become noticeable until 6-10 months, as far as differences in speech development and characteristics. Realize that the nature of the HL (degree, uni- or bilateral) will really affect when differences are noticeable and the magnitude of differences But even children who are deaf won’t show evidence of this until nearly 1 year--that’s why speech development differences haven’t ever been an effective way to id HL. What differences do we start seeing and when?? Quality and quantity of vocalizations are pretty similar between normally hearing and deaf babies thru about the first year. The most consistent trend is when canonical (reduplicative) babbling emerges for each group. For normal hearing babies, parents report evidence of this kind of babbling between 6-10 months (this is considered a normal range). Deaf babies showed evidence of this kind of babbling between 11 and 25 months. Notice that even the most precocious deaf baby didn’t show evidence of this kind of babbling within the normal range This is from Oller and Eilers, 1988

Variables Affecting Later Speech Intelligibility Age of identification/remediation We already talked about this Degree of impairment Focus more on aided thresholds Communication mode Oral programs tend to develop speech intelligibility best So how predictable is a child’s ultimate level of speech intelligibility based on characteristics of the HL Well, we already mentioned age of ident/remed. The earlier the better The degree of impairment (in terms of the PTA in the better ear) has long been the gold standard as the best predictor of eventual speech intelligibility. Research and experience has long held 70 dB HL average HL as the major dividing line. We know need to revise this in terms of the average aided thresholds from Has or Cis. Some researchers (Osberger, et al) at NTID report really favorable overall speech intell results from kids with average thresholds at 90-100 dB HL with appropriate amplification and a rigorous auditory/verbal program. Communication mode--how does the child’s preferred communication affect overall speech intell?? Does the use of primarily a manual communication system bode poorly for intelligible speech development?? Some argue it will Osberger (1994) found that kids with cochlear implants using total communication approach had significantly poorer speech intelligibility compared to kids with cochlear implants using oral communication Most likely due to the fact that only oral programs really focus on speech use, development, and intelligibility.

Speech Characteristics and Therapy Goals Children with mild/moderate degree of impairment Children with profound impairment Acquired hearing loss We will structure our discussion of the specific types of speech problems based on the degree of hearing loss since this seems to be the major variable determining the degree and type of speech concerns the client will bring to the therapy setting.

Speech Characteristics With Mild/Moderate Hearing Loss What’s normal Vowel production, voice quality, suprasegmental features Intelligibility What’s not normal Articulation of single consonants and consonant blends Substitutions, distortions, omissions Speech characteristics based on degree of HL: mild/moderate: vowel production, voice quality and suprasegmental features will be normal Primary errors related to articulation of single consonants or consonant blends Mostly of consonants characterized by reduced intensity, high freq, and short duration. Most involve errors of substitutions, followed by distortions. Omissions are infrequent

Speech Characteristics with Mild/Moderate Hearing Loss Phonologically, these children look like normally-hearing kids of a younger age These children develop and use speech sounds in the same order as normally hearing kids phonological analyses of samples from these kids suggest they produce errors comparable to younger normal hearing kids.

Speech Management of Mild/Moderate Hearing Loss Amplification is a must Clear understanding of the child’s aided hearing thresholds Articulation and phonological management can generally be approached in the same way as a normally hearing child but Don’t rely on auditory feedback cues Rely more on visual, tactile, and/or kinesthetic cues Be mindful of the developmental order of speech sound acquisition therapy: Keep in mind when working on these consonants, complexity of formation, visibility, and developmental order of acquisition. consider heightening use of visual, tactile and kinesthetic cues to compensate for reduced auditory input. Knowledge of child’s audiogram (aided and unaided) is crucial

Speech Characteristics of Deaf Children What’s normal Nothing What’s not normal Respiration, phonation, resonance, articulation, and suprasegmentals Intelligibility averages about 20%, but extremely variable on a case-by-case basis

Characteristics of Respiration Basic problems related to a general in- coordination of respiration and phonation Few syllables/breath Inhalation at inappropriate times Abnormally high airflow rates during phonation Breathy quality

Characteristics of Resonance Hyponasality Hypernasility

Characteristics of Phonation Inadequate vocal fold adduction Breathy voice quality Voiceless sound substitutions for voiced sound Inadequate control of vocal fold vibration Abnormally high pitch Pitch change is restricted across utterances Inadequate control of laryngeal activity Speech intensity too high or too low Lack of loudness variation and control across utterances Breathiness or glottal resistance

Characteristics of Articulation Individuals are extremely variable in the number and type of articulation errors seen Vowel errors Vowel neutralization, diphthong and vowel confusions, nasalization of vowels Consonant errors Errors of voicing, omission and distortion of consonants, omission of consonant blends, nasalization of consonants Impaired coarticulation movements

Characteristics of Suprasegmentals Slower than normal speaking rates (1.5-2 times) Individual phonemes prolonged Lengthy pauses within utterances Pauses are more numerous and longer than normal Abnormal intonation patterns One of the biggest variables determining overall intelligibility Suprasegmental features communicate emotional intent, urgency of the message, and linguistic stress

Increasing Speech Production and Intelligibility Maximizing residual hearing Appropriate amplification is a must Anatomical and pictorial monitoring Picture representations of tongue placement during phoneme production Visual stimulation and feedback Mirrors Feedback devices Visipitch, SpeechViewer, palatometers

Speech Characteristics of Acquired Hearing Loss Extremely variable effects Usually the degree of hearing loss has to be very significant, especially in the high frequencies Decline in intelligibility is gradual and due to loss of auditory feedback Typical errors Production of siblants, final consonants, voice quality, loudness control, rhythm Speech characteristics of acquired HL very little information on them generally the decline is gradual and extremely variable. typical errors might include--production of sibilants, final consonants, voice quality, loudness control, and rhythm.