Top Lang Disorders Vol. 38, No. 3, pp. 202–224 Guiding

Top Lang DisordersVol. 38, No. 3, pp. 202–224Copyright c© 2018 Wolters Kluwer Health, Inc. All rights reserved.

Guiding Principles andEssential Practices of Listeningand Spoken LanguageIntervention in the School-AgeYears

Uma Soman and Mary Ellen Nevins

Listening and spoken language (LSL) intervention and education have emerged as the preferredterms representing an intervention perspective that promotes “auditory oral” outcomes for many oftoday’s children who are deaf or hard of hearing (D/HH), including those who are English learners.Practitioners (including speech–language pathologists, educational audiologists, and teachers)working with students who are D/HH require access to evidence-based principles of LSL. A deepunderstanding of general principles will inform practitioners’ development of intervention topromote outcomes for school-aged students who are D/HH or D/HH and English learners. Thepurpose of this article is to identify principles and practices foundational to developing LSL.Knowledge, skills, and dispositions for practitioners are discussed; descriptions and examplesof strategies and resources associated with LSL are included. Key words: auditory oral, deaf,hard of hearing, hearing technologies, language intervention, listening and spoken language,school-aged children, speech–language pathologists

OVER the last two decades, more childrenwho are deaf or hard of hearing (D/HH)

are using hearing technologies, such as hear-ing aids and cochlear implants, and receiv-ing early intervention to develop listening and

Author Affiliations: Carle Auditory Oral School,Carle Foundation Hospital, Urbana, Illinois(Dr Soman); and Audiology & Speech PathologyDepartment, University of Arkansas for MedicalSciences, Little Rock (Dr Nevins).

The authors have indicated that they have no financialand no nonfinancial relationships to disclose.

Supplemental digital content is available for thisarticle. Direct URL citations appear in the printedtext and are provided in the HTML and PDF ver-sions of this article on the journal’s Web site (www.topicsinlanguagedisorders.com).

Corresponding Author: Uma Soman, PhD, Carle Au-ditory Oral School, Carle Foundation Hospital, 611 W.Park St, Urbana, IL 61801 ([email protected]).

DOI: 10.1097/TLD.0000000000000158

spoken language (LSL). When given a choice,a majority of families want their children tolearn their home language(s) and use hearingaids or cochlear implants to develop auditoryskills (Alberg, Wilson, & Roush, 2006). Thecultural and linguistic diversity of the studentswho are D/HH is similar to that observed inthe larger population, and for a growing num-ber of families, the home language might beone other than English or one in addition toEnglish.

There has also been a shift in educationalplacements such that students’ time is maxi-mized in general education settings instead ofschools or programs specifically for childrenwho are D/HH. Many of these students receiveintervention from interprofessional teams thatmight include speech–language pathologists(SLPs), teachers of students who are D/HH,special education teachers, general educa-tion teachers, reading specialists, and Englishlanguage teachers. A certified Listening and

Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

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LSL Principles and Practices 203

Spoken Language Specialist1 (LSLS) has expe-rience and expertise in working with studentswho are D/HH and ought to be included onthe interprofessional team; however, only alimited number of professionals are currentlyprepared and certified for this specialization(Alexander Graham Bell Association for theDeaf and Hard of Hearing, 2017).

Outcomes of students who are D/HH, espe-cially those who are English learners (ELs), areinfluenced by a number of intrinsic factors,some of which are essentially immutable, aswell as extrinsic factors, over many of whichthere is a degree of control. Importance ofintervention in the first 3 years of life hasreceived much attention at the levels of re-search, practice, and policy. As a result, chil-dren who are D/HH currently start their ele-mentary years with varying levels of readinessto enter kindergarten. Readiness skills oftenreflect the quality and quantity of early inter-vention services children have received, buteducation and intervention across the school-age years continue to be critical for build-ing language foundations for literacy develop-ment and for employment and social successin later life. Thus, it is critical to explore theLSL needs of students who are D/HH in thecontext of academic and social developmentthat occurs during the elementary and middleschool years.

In this article, we propose three Profilesof Potential—Keep Up, Catch Up, MoveUp. These three profiles create a conceptualnomenclature that describes 5- to 14-year-oldstudents based on their needs, growth trajec-tories, and the family’s desired outcomes. Itprovides shared terminology for working ininterprofessional teams and with families. Inaddition, this nomenclature can be applied to

1The Listening and Spoken Language Specialist certifica-tion is awarded by the Alexander Graham Bell Academyfor Listening and Spoken Language to individuals with de-grees in audiology, speech–language pathology, or deafeducation upon the completion of advanced coursework,mentoring, and a passing score on the certification exam-ination.

children who are D/HH and ELs. To date, lit-tle has been written on the needs of thesestudents. This article is offered to contributeto the conversation regarding children whoare D/HH and who are learning at least twospoken languages.

Practitioners working with students whoare D/HH and who are ELs will benefit froman understanding of the impact of hearing losson language and academic development con-sidered in the context of dual language learn-ing. There exists a body of knowledge andevidence-based strategies that can inform in-tervention for each student who is D/HH toachieve his or her personal best, includingthose who are ELs.

GUIDING PRINCIPLES OF LSLINTERVENTION

On the basis of a synthesis of knowledgefrom within the field, coupled with insightsfrom our experience working with this pop-ulation, we offer five principles for plan-ning and implementing LSL intervention withschool-aged children and adolescents who areD/HH and who come from culturally and lin-guistically diverse backgrounds. Before ex-ploring these principles for adoption and im-plementation, impact of hearing loss and itsprescribed management are reviewed.

The guiding principles and essential prac-tices of LSL intervention for school-aged chil-dren are intended to extend knowledge andskills of practitioners who strive to meet thevaried needs of students who are D/HH andto encourage sensitivity to cultural–linguisticvariation. In our exploration of these princi-ples, we share examples from our practice aswell as composite vignettes of students thatpractitioners might encounter. The five prin-ciples are as follows:

1. Intervention maximizes learning to listenand learning through listening.

2. Language and literacy development isfoundational to all interventions and tar-geted directly.

3. Intervention is individualized, system-atic, and richly multidimensional.


204 TOPICS IN LANGUAGE DISORDERS/JULY–SEPTEMBER 2018

4. Effective intervention is driven by inter-professional practice (IPP).

5. Families are included and empoweredto be partners in listening, spoken lan-guage, and literacy development.

Impact and management of hearing loss

Application of the five principles requiresa deep understanding of the impact of hear-ing loss and the need to manage it effec-tively. Hearing loss limits auditory access tospeech and language present in the child’s en-vironment. Prelingual hearing loss has a neg-ative impact on development of spoken lan-guage(s) and can also have a cascading effecton social–emotional and academic develop-ment. Every state (and territory) in the UnitedStates has an established Early Hearing Detec-tion and Intervention (EHDI) program. Hear-ing screening by 1 month (but preferably be-fore a child leaves the birthing hospital), iden-tification of hearing loss by 3 months, and en-rollment in intervention by 6 months (calledthe 1-3-6 protocol) is the gold standard rec-ommended by the National Center for Hear-ing Assessment and Management and its EHDIprograms (Joint Committee on Infant Hear-ing, 2007; Joint Committee on Infant Hearingand Muse et al., 2013). This aggressive proto-col has been developed in response to an un-derstanding of brain neuroplasticity (Dorman,Sharma, Gilley, Martin, & Roland, 2007; Kral& Sharma, 2012) and the importance of hear-ing for typical language acquisition (Fernald &Simon, 1984; Kuhl, 2004, 2010; Moon, Lager-crantz, & Kuhl, 2013).

A growing number of studies are demon-strating the effectiveness of timely identifica-tion and intervention for children who areD/HH (Geers, Moog, Biedenstein, Brenner,& Hayes, 2009; Moeller, Tomblin, Yoshinaga-Itano, Connor, & Jerger, 2007; Moog & Geers,2010; Niparko et al., 2010; Yoshinaga-Itano,Sedey, Wiggin, & Chung, 2017). Yoshinaga-Itano et al. (2017) compared the effects of ad-herence to the 1-3-6 protocol on vocabularydevelopment of children who are D/HH anddiscovered that “vocabulary quotients weresignificantly higher for children who met the

EHDI guidelines” than for the outcomes ofchildren who did not meet the recommendedtimetable (Yoshinaga-Itano, 2003; Yoshinaga-Itano et al., 2017). The EHDI bill was reautho-rized in November 2017 and will continue torecommend and support 1-3-6 for infants whoare D/HH.

Per the latest data available, 98.2% of allinfants born in a hospital are screened forhearing loss. Unfortunately, approximately30%–40% of children who are referred foradditional assessments do not meet theserecommended starting points and are lostto follow-up due to a variety of factors andmitigating circumstances (Centers for DiseaseControl and Prevention, 2015). This results inunmanaged hearing loss that can have a con-siderable negative impact on developmentof LSL. Here, unmanaged can refer to lateridentification of hearing levels, delayed fittingof hearing technologies, and/or no access toskilled professionals to guide family-centeredintervention. Fortunately, early identification,early amplification, and early intervention canmitigate the negative impacts of hearing loss(Joint Committee on Infant Hearing, 2007;Joint Committee on Infant Hearing and Museet al., 2013). Generally speaking, approxi-mately 90% of infants who are D/HH are bornto families with normal hearing (Mitchell &Karchmer, 2004) and, not surprisingly, a vastmajority of families choose to communicatewith their child in the spoken language ofthe home (Alberg et al., 2006).

Families who choose the spoken lan-guage(s) of the home as the desired outcomefor their child naturally have a “communica-tion match” between their language and thechild’s language. That said, they might beless knowledgeable regarding issues relatedto hearing loss, device management, and in-tentional auditory skills development. Whencoached by a highly qualified early interven-tionist specializing in working with familiesof children who are D/HH and are developingLSL, the opportunity to jump-start the learningjourney and positively influence its trajectoryis eminently possible. If the interventionist,although specialized in developing LSL is not



fluent in the family’s spoken language, thechild’s language acquisition process may beimpacted.

Without the linguistic skills and/or the cul-tural competence to coach families directly inthe home language and understand the influ-ence of the home language on learning spo-ken English not only are practitioners at a dis-advantage but so too are children and families.One must consider the “double-challenge” ef-fect on children who are both D/HH and ELs.Given the linguistic diversity of the familiesand children served, and the limited numberof qualified LSL professionals overall, the chal-lenge of providing excellent early interven-tion needs to be addressed on a case-by-case,location-by-location basis to design the bestservice delivery plan by an interprofessionalteam of practitioners. Regardless of the lan-guage in use, practitioners who commence in-tervention with dedicated knowledge, skills,and dispositions for working with childrenwho are D/HH and their families are poisedfor the greatest success (Sass-Lehrer, Moeller,& Stredler-Brown, 2015).

Profiles of potential

Given the variety of factors that influencea child’s early intervention journey, childrenwho transition from early intervention intothe school environment might be startingat different levels of proficiency in their lis-tening skills, home language(s), and social–emotional development. Practitioners shouldconsider each student uniquely and identifystrengths and areas of needs in each domainto plan intervention. However, we suggestthat students who are D/HH might be char-acterized by one of three possible profiles ofpotential as they move into traditional educa-tional settings from early intervention.

Conceptualizing these loosely organizedprofiles of potential might assist practitionersin developing and targeting objectives that arechallenging but proximal and achievable forthe students for whom they are written. Us-ing terms that emphasize an active, generallearning outcome desired for students in eachgroup, these profiles of potential can guide

families and practitioners to work together tohelp a student Keep Up with typically hear-ing classmates, Catch Up to same-aged class-mates, or Move Up to attain the next appropri-ately targeted milestone in development. Thefollowing descriptions may clarify the differ-ences between each of the suggested perfor-mance profiles.

Keep Up

Students who are challenged to Keep Uphave experienced early identification andintervention resulting in “at or near” age-appropriate listening, speaking, and readingabilities. They must continue to develop skillsin order to keep up with the ever-expandinglinguistic and academic expectations of theirgrade level and typically hearing classmates.

Catch Up

Students who require support to help themCatch Up are those who have benefittedfrom LSL intervention but likely have hadan idiosyncratic challenge (late identification,poorly fit device, limited intervention, etc.)as part of their early development. Most of-ten these students have made steady progressover the years but do not yet have age-appropriate listening, speaking, and readingskills. Each child will likely need intense inter-vention (from an LSL practitioner) to developage-appropriate LSL skills to catch up with hisor her classmates.

Move Up

Students who are encouraged to Move Upare those who, in addition to being identi-fied with hearing loss, have secondary diag-noses such as visual impairment, autism spec-trum disorder, learning disability, etc. In thesesituations, the student might exhibit substan-tial delays in one or more areas of develop-ment and/or academic achievement. Thesechildren can still make progress with appro-priately selected and functional listening andlanguage intervention; in so doing, engage-ment with their family and their communityis enhanced.



Principle 1: Intervention maximizeslearning through listening

The first principle focuses on facilitatinglanguage and literacy development throughsystematic auditory skill development. Thisassumes access to the speech spectrumthrough well-fit and consistently wornhearing technology—hearing aids, cochlearimplants, and/or bone-anchored hearingdevices. Research suggests that even amild degree of hearing loss is educationallysignificant and can disrupt the integrity ofauditory input, leading to negative impacton development of auditory skills essentialfor language acquisition and language com-prehension (Bess, Dodd-Murphy, & Parker,1998; Tomblin et al., 2015).

Maximize audition

In typical development, hearing is a first-order event in the process of language ac-quisition (Cole & Flexer, 2015). However,speech perception is an audiovisual activityin which typically developing infants are at-tending to the sounds and rhythm of thelanguage along with observing the lip move-ments of their caregivers (Kuhl & Meltzoff,1982; Lewkowicz, 2010). Through a seriesof maturational processes combined with lin-guistic experiences infants learn to detectand discriminate the sounds of their na-tive language (Kuhl, 2004; Maurer & Werker,2014). Attuning to the sounds of one’s na-tive language begins in utero and is evidentsoon after birth. Newborn infants show apreference for listening to speech, particu-larly the language they heard in utero, com-pared with nonspeech stimuli (Vouloumanos& Werker, 2004, 2007) and compared withspeech sounds from an unfamiliar language(Moon et al., 2013). Infants can discriminatebetween languages from different rhythmclasses, for example, English from French by3 months (Nazzi, Bertoncini, & Mehler, 1998).

At the segmental level, infants can discrim-inate between vowels from native and non-native languages (e.g., German vowels /U-Y/and English vowels /i-a/) by 4 months (Polka& Werker, 1994) and demonstrate categorical

perception of vowels in their native languageby 6 months (Kuhl, 2004; Kuhl, Williams,Lacerda, Stevens, & Lindblom, 1992). By12 months, infants with typical hearingcan discriminate the consonants of theirnative language (see review by Kuhl, 2004).Furthermore, infants demonstrate familiarityand preference to the sounds of their nativelanguage versus non-native language (Cheouret al., 1998; Rivera-Gaxiola, Silva-Pereyra, &Kuhl, 2005; Tees & Werker, 1984).

This phenomenon of perceptual narrow-ing or perceptual attunement is fundamen-tal to native language acquisition (Maurer &Werker, 2014). Infants in bilingual or multi-lingual home environments show some dif-ferences, including later demonstration ofattunement to the phonemes in the homelanguage (Byers-Heinlein & Fennell, 2014).However infants and toddlers who havemeaningful exposure to the home languagesdemonstrate perceptual attunement to them(Bijeljac-Babic, Serres, Hohle, & Nazzi, 2012;Burns, Yoshida, Hill, & Werker, 2007; Garcia-Sierra et al., 2011; Weikum et al., 2007).It is important to note that this protractedtimeline is not a delay caused by being in abilingual environment but rather an alterna-tive timeline of development of simultaneousbilingualism.

These findings suggest that babies who areborn with congenital hearing loss (presentat birth) will have lost valuable listeningtime before they take their first breath andwill have much to decipher when theygain access to audible speech and languagethrough their hearing technology. It has beenproposed that even those who are usinghearing technology experience some degreeof auditory deprivation (Conway, Pisoni, &Kronenberger, 2009), which might impactneural development. Because auditory accessthrough hearing technology does not exactlyreplace natural acoustic hearing, it might alterhow the brain processes and lends weight tothe meaning of auditory input in the contextof other sensory experiences (Gilley, Sharma,& Dorman, 2008; Sharma, Gilley, Dorman, &Baldwin, 2007). The impact of early auditorydeprivation and altered auditory input is



currently under investigation, so mindfulpractitioners should be alert for additionalscientific evidence that will better informtheir practices and expectations.

When providing LSL intervention to stu-dents who are D/HH, practitioners shouldnote that, although hearing technology pro-vides access to sound, it is not perfect. Stu-dents might not attend to their auditory envi-ronment all the time and might only tune inwhen they are directed. For beginning listen-ers (e.g., students who receive their hearingtechnology at a time coinciding with enroll-ment in school), the auditory stream might beoverwhelming and indecipherable, necessitat-ing need for direct instruction. It is importantto gauge the audibility or auditory benefit de-rived from the hearing technology. Questionsto ask include the following: Can the studenthear all the speech sounds in his or her spo-ken language(s)? Does the student have ade-quate access to hear the difference betweenphonemes that vary by a single feature suchas manner (e.g., /d/ vs. /n/), place (e.g., /k/vs. /t/), or voicing (e.g., /b/ vs. /p/)? Howwell does the student hear in a noisy situa-tion? Consultation and collaboration with apediatric audiologist or an educational audiol-ogist can lead to an appropriate audiologicalmanagement plan that is attuned to the chang-ing listening needs of students and maximizesauditory access in all learning environments.

Consider the following scenario of a third-grade student, Alex, who is on a Catch Uptrajectory:

Alex was adopted at 18 months and identified ashaving severe hearing loss at 24 months. He worebilateral hearing aids and received specialized in-struction in an early childhood program for stu-dents who are D/HH. By the end of second grade,Alex had near age-appropriate language scores andentered third grade in his neighborhood school.He received support from a teacher for studentswho are D/HH, as well as from an SLP and an edu-cational audiologist. Three months into the schoolyear, Alex began complaining about the classroombeing very noisy during group work. After observa-tions and assessments, the educational audiologistrecommended a change in hearing aid program-

ming and upgraded assistive listening technology.This adjustment in Alex’s access to the auditory sig-nal subsequently maximized his learning throughlistening.

Targeting the hierarchy of listeningskills

Upon receiving hearing technology, mostchildren have to learn to listen to the audi-tory input to make sense of what they arehearing. This process typically involves learn-ing to detect, discriminate, identify, and com-prehend information presented in an auditory-only manner. This hierarchy of listening skills(Erber, 1982) provides a roadmap for devel-oping these skills and maximizing learningthrough teaching children directly how tolisten.

Erber’s (1982) seminal work with childrenwith all degrees of hearing loss led to con-ceptualization of four distinct stages of au-ditory skill acquisition, using terms that al-low professionals to communicate preciselywhat a student is capable of doing using hear-ing alone—detection, discrimination, identi-fication, and comprehension. When a task isauditory-only, no visual cues are available tothe listener, thus truly ascertaining the contri-bution of the hearing technology to learningauditorally. Each of the four stages of the au-ditory skill hierarchy is elaborated as follows.

Detection

This is the most basic auditory skill wherethe listener simply indicates awareness that asound is present (or absent) and is the founda-tion upon which more sophisticated auditoryresponses build. Because detection is requiredfor all later stages of auditory skill develop-ment, early fitting of hearing devices is essen-tial to jump-start auditory learning. Determin-ing a child’s unaided detection level is theentry point for choosing the hearing tech-nology that will make spoken language inputaudible. For school-aged students who areD/HH, it is easy to confuse detection withhigher levels of auditory skill; it is all toocommon for a teacher to report that a child ishearing when he or she responds to a passing



fire truck or a voice command that simplygets the child’s attention that somethingis happening. For example, during quietreading time, the teacher may indicate thatit is “time for gym.” The developing listener,however, may only hear the teacher’s voicecoming out of the quiet and look up to seewhat the rest of the students are doing andtake a cue from their actions. These areexamples of sound-only detection.

Discrimination

The ability to identify whether two stimuliare the same or different is discrimination.Generally speaking, this is not a skill that istargeted separately in instruction but rather aspart of an intervention strategy on the road tofine-tuning the auditory skills required at thelevel of identification. Typically implementedafter the student has misheard, this same–different judgment ability in more advancedauthentic communication tasks will assist theyoung listener in knowing that dog and frogare not one and the same animal; the wordsbook and books differentiate in number; andin and on represent varying spatial relation-ships. Discrimination tasks without an under-lying language or literacy objective are notgenerally targeted for instruction. However,they might be useful as an intervention probeto determine what the student has heard. Forexample, in a phonological awareness taskcombining onsets and rimes, a student mayincorrectly create the word big when /d/ andig are presented. In this case, a quick check todetermine whether the student can discrimi-nate between /d/ and /b/ will drive the nextstep. If the student can discriminate betweenthe two phonemes, saying big instead of digmight be related to articulation errors or evenvocabulary limitations.

Practically speaking, the discriminationskills of a student who is D/HH are greatlyinfluenced by the programming of the hear-ing technology, which should be fit to en-sure adequate access to the speech spectrum.The audiologist should be conducting peri-odic speech perception testing at the sound,word, and sentence levels to ensure the ap-

propriate fit and function of hearing tech-nology. Speech perception is strongly linkedto speech production (Eisenberg, 2007), sounderstanding a student’s speech perceptionscores is essential to planning and implement-ing articulation therapy. Daily and routine lis-tening checks are essential to ensure that achild’s access and baseline functional perfor-mance is the starting point of every listen-ing day and therapy session. The Ling SoundCheck (Ling, 2006) is a quick and easy taskthat is used for this purpose; a child neveroutgrows the need for a check against hisor her own standard performance. Deviationfrom expected performance may be an indi-cator of device malfunction or change in hear-ing status; teachers and SLPs are encouragedto learn more about why and how to per-form the Ling Sound check. For more infor-mation about speech perception assessments,see Supplemental Digital Content A (availableat: http://links.lww.com/TLD/A59).

Identification

The skill in which a stimulus is recognizedand acted upon is identification. The stu-dent’s response, either motoric or linguistic,provides a window into the hearing brain.For the young listener, examples of identi-fication include recognition of receptive vo-cabulary and responses to language that canbe ascertained through an auditory-only pre-sentation. When directed to pick one banana,two oranges, or five grapes, a preschoolerwho can select the ingredients of a fruit salad(given an auditory-only presentation of theitem) is demonstrating auditory identification.For the older listener, responding correctly toan auditory-only prompt, spoken without vi-sual/lipreading cues, for example, “point toAustralia on the map,” is also an example ofthe skill of auditory identification.

Additional tasks that require identificationmight include writing math problems in alistening-only condition or repeating corestatements of fact from the science unit as pre-sented with no visual cues. Often times, inter-ventionists present closed sets of all possibleresponses as an instructional/interventional


http://links.lww.com/TLD/A59


strategy. Limiting the possible responsesassists the student in being successful withauditory tasks. Closed sets support thedevelopment of increasingly sophisticated lis-tening skills overlaid onto an ever-expandinglanguage repertoire. However, if a studentis unable to complete a task even with fullaccess to auditory and visual cues, it is highlyunlikely that the student will be able todo so in an auditory-only condition. This isespecially noteworthy for students trying toCatch Up who rely on continued listeningand language intervention/education becauseof their idiosyncratic needs. In essence, thepractitioner guides the student through a se-quential ratcheting of auditory competence inthe context of an expanding linguistic skill set,particularly as the language of instruction be-comes more complex and learning advances.

Comprehension

The most sophisticated level of auditoryskill development is comprehension. It isconsidered by many to be the final outcomeof LSL intervention and education. Theinterrelationship of listening and languagecontinues to impact ability, but simplystated, auditory comprehension suggests thecapacity to do more than just identify orname the linguistic stimulus. Instead, thelistener is required to act upon or respondto the auditorally presented message. Forexample, when asked a question (throughaudition alone) “What are the stages of thewater cycle?” the student who understandsthe question does not simply repeat back thestimulus. Instead, he or she responds with theanswer to the inquiry by saying, “evaporation,condensation, and precipitation.” Thus, thestudent demonstrates auditory comprehen-sion, along with memory and retrieval of factslearned previously or available in the text.

In pursuing the development of the audi-tory skills of detection, discrimination, identi-fication, and comprehension in parallel withthe development of increasingly sophisticatedspoken language ability and literacy skills, thepractitioner is encouraged to utilize strate-gies that are part of LSL practice. Fickenscher

and Gaffney (2015) describe these strate-gies in an open-source document for whicha link is provided in Supplemental DigitalContent A (available at: http://links.lww.com/TLD/A59).

For children who are D/HH and EL, thesame hierarchy of listening skills applies. Ifproficiency in the home language is a desiredoutcome, practitioners and families couldwork toward developing auditory compre-hension of the home language as well as En-glish. This will allow students to participatemore fully in their cultural community as wellas at school.

Maximize device wear time

Finally, the principle of maximizing (spo-ken language) learning through listening de-mands consistent use of hearing technology.Wear time is a factor that contributes to anystudent’s improved performance with hear-ing technology. It is within control of thefamily, SLPs, and teachers, but it is not al-ways easy to ensure. Internal data logging fea-tures in both hearing aids and cochlear im-plants can now help monitor wear time ofthe device. The cumulative effects of constantwear time contribute to better auditory per-formance with hearing devices (Walker et al.,2013, 2015). Another issue related to learn-ing through listening is that of listening fa-tigue. Recent studies in students with hear-ing loss (Bess, Gustafson, & Hornsby, 2014)underscore the effort that is required to bean active auditory participant in classrooms.For more information about listening fatiguein students who are D/HH, see sources inSupplemental Digital Content A (available at:http://links.lww.com/TLD/A59).

Principle 2: Language and literacydevelopment is foundational to allintervention

After families have chosen spoken languageas the primary mode of communication andlearning for their child, all LSL interventionsfor school-age children should be guided byand focused upon the development of lan-guage and literacy skills essential for achieving






academic proficiency, social competence,and other desired outcomes. The constructof literacy encompasses the ability to listen,speak, read, and write using a literate style.

Childhood hearing loss can have a nega-tive impact on development of the essentiallyinterdependent skills of listening, speaking,reading, and writing. For example, a studentusing hearing aids might not clearly hear theregular past tense marker -ed and understandthat it denotes an action that has happened.It is then likely that the student does notuse -ed in his or her spontaneous spokenlanguage and does not attend to this mor-pheme when presented in a text. It mightfollow that this absent morpheme will notappear in his or her written language. Forstudents who are D/HH, deficits in oral vo-cabulary and morphosyntactic developmentcan impact literacy development but canbe addressed through intervention (Gross &Robertson 2017). Literacy instruction and in-tervention that take into account the uniqueimpact of hearing loss are well within thescope of practice of the LSL professional, aswell as the SLP (American Speech-Language-Hearing Association [ASHA], 2001). A collab-orative approach for implementing interven-tion is recommended. Within discussion ofthis principle, we focus on the developmentof vocabulary and complex language whilerelating it to development of all aspects ofliteracy.

In typical development, spoken languageacquisition relies on optimal perception ofthe language(s) in a child’s environment,as provided through meaningful linguisticinteractions with caregivers (Hirsh-Pasek &Golinkoff, 2012; Konishi, Kanero, Freeman,Golinkoff, & Hirsh-Pasek, 2014; Ramırez-Esparza, Garcıa-Sierra, & Kuhl, 2014). Asstated previously, congenital hearing loss notonly impacts the development of listening,language, and speech skills but also has anindirect effect on development of academicand social skills (Antia, 2011; Antia, Jones,Reed, & Kreimeyer, 2009; Dammeyer, 2010;Moeller, 2007; Moeller et al., 2007). Hearingtechnology can restore access to the auditory

features of language and speech, but develop-ment of spoken language in early childhoodyears and literacy in the school years must befostered through intentional intervention forthese children.

Thus, it follows that the goal of LSL inter-vention is acquisition and maintenance of age-appropriate auditory, language, speech, aca-demic, and social skills. Historically, studentswho are D/HH have demonstrated deficitsin reading (Traxler, 2000) and other aca-demic achievements. However, a review ofmore recent literature indicates that manypreschool and school-aged students who areD/HH and receive timely and effective LSLintervention can develop age-appropriate vo-cabulary (Yoshinaga-Itano et al., 2017), spo-ken language and literacy (Geers et al., 2017;Mayer & Trezek, 2018), and academic skills(Antia et al., 2009).

In typical development, quality and quan-tity of language input, along with caregiverengagement, are factors that influence fu-ture language outcomes. Children who are inlanguage-rich environments, engage in mean-ingful conversations, and participate in sharedbook reading with caregivers have a strongfoundation for language and literacy. Thesame is true for children in bilingual home en-vironments in which they are exposed to twoor more languages and developing them si-multaneously. For children who have a strongfoundation in one language and then learn asecond language, there might be a protractedlearning period but the strong foundation inthe first language likely assists in learning thesecond language.

Learning two languages that differ in modal-ity such as American Sign Language and spo-ken English can be considered bilingual, andit can demonstrate certain features of spokenbilingualism such as code switching and in-serting vocabulary from one language in thesyntactic frame of the other. However, suchinstances are beyond the scope of this article,which focuses on developing two or morespoken languages, which often include sce-narios in which the student is an English lan-guage learner.



Given the importance of having a stronglanguage foundation in early childhood, re-cent research and public policy are focusedon developing interventions such as ThirtyMillion Words Initiative (Leffel & Suskind,2013; Suskind et al., 2016) and “Reach Outand Read” (Weitzman, Roy, Walls, & Tom-lin, 2004; Zuckerman & Khandekar, 2010).These programs are being implemented toclose the language gap for children in mono-lingual, bilingual, and/or low socioeconomicenvironments.

Researchers who work with students whoare D/HH are developing similar interventionsthat take into account the impact of hearingloss in addition to the demographic factors.Cruz, Quittner, Marker, and DesJardin (2013),for example, identified parallel talk, open-ended questions, and expansion as high-level language facilitation strategies that con-tributed to growth in expressive language ofstudents who are D/HH, irrespective of thefamily’s socioeconomic status. Currently, re-search on the development of students whoare D/HH and EL is sparse. That said, under-standing the overlap between language in-tervention strategies for D/HH and EL canprovide guidance when developing age- andstage-appropriate targets and is discussed asfollows.

Vocabulary developmentand intervention

Learning the words of a language is fun-damental to the comprehension and expres-sion of thoughts and ideas. Whereas somewords might be intentionally taught to youngchildren by their families, a vast majority ofwords are learned incidentally by encounter-ing them in meaningful natural contexts. Forexample, a typically developing preschoolermight know the words spoon, fork, and knifethrough intentional instruction by families butmight learn the word chopsticks in the con-text of eating Chinese food at a restaurant.In fact, a large majority of words acquiredin early childhood are learned through inci-dental learning whereas only a small minority

of words are learned from direct instruction(Bloom, 2002; Christ & Wang, 2010).

For many students who are D/HH, develop-ing vocabulary can be challenging. The resultis a vocabulary that is limited in size, breadth,and depth (Lund, 2016). For students who areD/HH and EL, learning words for the same ob-ject and concept across languages can presentan additional challenge. A student who speaksArabic at home might have a majority of food-and family-related vocabulary in Arabic butnot in English, and vice versa for vocabularyrelated to academics. Deficits in vocabulary inone or more languages will likely impact per-formance in the classroom as well as socialinteractions at school and create confoundingfactors during assessments.

Elementary school students are expectedto acquire at least 8–10 new words per week(Biemiller, 2003; Biemiller & Slonim, 2001;Nagy & Anderson, 1984) through interactionswith individuals, engagement with texts,and incidental learning. All students need toexpand the size, breadth, and depth of theirvocabulary to meet the demands of academicinstruction. Many education and languageprofessionals are aware of the work of Beck,McKewon, and Kucan (2013), who classifyvocabulary into three tiers. Tier 1 vocabularyrepresents basic words or the first words forconcepts, for example, baby, mommy, big,happy, like. Tier 2 vocabulary representswords frequently used in mature language, forexample, infant, parent, enormous, joyful,adore, and are encountered in a variety ofcontexts, especially in grade-level readingmaterials. Tier 3 vocabulary represents wordsthat are rarely used and mostly in specificcontexts, for example, sedimentary, ento-mology, excavate. Tier 1 vocabulary mightbe sufficient to have a basic conversation inorder to meet needs and wants, but Tier 2 vo-cabulary is essential for learning and engagingin an exchange of ideas as students and adults.

Limited vocabulary, especially Tier 2 vocab-ulary, can impact learning of concepts andnew vocabulary for all students but especiallyfor those who are D/HH. Consider an ele-mentary school scenario in which the teacher



states, “Texts that are make-believe are fic-tion, and those that are real are nonfiction.”The key words in this sentence are texts,make-believe, real, fiction, and nonfiction.Typically developing students might be famil-iar with the words make-believe, and real,making it possible for them to deduce whatfiction and nonfiction mean. However, thestudent who is D/HH might not fully under-stand what make-believe and real mean. Ifnot, this student will not be able to grasp themeaning of these terms as quickly as class-mates. Many state curricula expect studentsto master these concepts by the end of firstgrade. One can imagine how difficulty withthese seemingly simple vocabulary and con-cepts can impact future learning of concepts,such as genre and realistic fiction, putting thestudent even further behind.

To advance vocabulary development, prac-titioners must be proactive in identifying con-textualized vocabulary and concepts (in ad-dition to those identified by the Teacher’sGuide) that are not only important for under-standing a particular text but also applicablein other contexts. For example, learning thewords destination, breathtaking, and tower-ing, in preparation for an unit on nationalparks and landmarks, will not only facilitatelearning of the target content but could alsolead to more precise word choice when shar-ing commentary about story settings or evenfamily travel.

Previewing a classroom lesson during anintervention session and emphasizing the vo-cabulary and concepts within the unit canlevel the playing field for learning and pre-pare the student to engage in academic con-versations with his or her classmates. Experi-encing the information a second time duringclassroom instruction might allow the studentto use the target vocabulary when participat-ing in the lesson. For many students who areD/HH, previewing target vocabulary can beincorporated as an objective in the Individu-alized Education Plan (IEP) and addressed byteachers and SLPs.

Unfortunately, simply encountering newwords is not sufficient to create the vocab-

ulary infrastructure that assists in later accessto previously learned words. Whether newwords are learned through direct instructionor incidentally, incorporating them into theexisting semantic organization is essential forefficient retrieval. Consider the following sce-nario of a fictionalized middle school student,a bilateral hearing aid user, who is on a KeepUp trajectory.

Jayla knows the words electricity from a lessonon Benjamin Franklin and electrician from a vo-cabulary list related to occupations. As Jayla pre-pares for a science unit on modern technologiesand engineering, she learns the words electric andelectronic. It is important to consider how she in-corporates and organizes these words in the con-text of her existing vocabulary. Does she have ad-equate word study skills to understand that all ofthese words have a common origin and then ex-tend it to the word electron but not election? Howdo deficits in understanding prefixes, suffixes, andgrammatical morphemes impact listening, speak-ing, reading, and writing?

Students who are D/HH are often catchingup to what their classmates might know andthen trying to learn additional new words.Thus, efficiency in teaching vocabulary andhelping situate it in an existing semantic mapis necessary on the practitioner’s part. Con-sider teaching the word habitat. It can betaught by pairing an unknown word witha known word and creating a “vocabularysandwich” and acoustically highlight the tar-get word during instruction. “Habitat is thehouse or environment that people or animalslive in. Habitat. The camel lives in a deserthabitat.” In this brief interaction, the prac-titioner repeats the target word three timeswithin a meaningful context and providesclues to situate it in an expanding semanticmap.

A general rule of thumb is that typicallydeveloping children need to hear a word15–20 times in order to learn it. It has beenproposed that students who are D/HH mightneed up more repetitions for learning thesame word. Practitioners should considercreating multiple opportunities for exposureto relevant words. For example, repeated



exposure to the word camouflage in re-sponse to a child’s saying “I have soldierpants and soldier backpack” could supportmeaningful learning of age-appropriate lan-guage. Taking the opportunity to understandand learn these precise words can lead tomore sophisticated language, avoiding theperception of the students as being childishor immature by adults and/or peers.

Complex language developmentand intervention

Vocabulary intervention can propel astudent’s understanding and use of age-appropriate vocabulary in academic domains,but it is incomplete without adequate atten-tion to mastery of complex syntax. Stringingtogether a few words or using simple sen-tences with a single verb phrase may be suffi-cient to communicate basic needs and wants,but complex syntax (i.e., sentences with oneor more clauses, each with its own verbphrase) provides an efficient way to commu-nicate multiple ideas and relationships amongthem. For example, a routine direction such as“Before you go to recess, complete the wordproblems on page 65” can be challenging ifthe student does not understand the mean-ing and function of the conjunction beforeor if the student applies the order-of-mentionstrategy when interpreting the given directionand starts to leave for recess. If the studentdoes not follow the direction, it might be per-ceived as “misbehavior” or inability to followdirections when, in fact, it might be neither.A teacher’s redirection (or perhaps even chas-tisement) for failure to complete the task asassigned could be confusing, disappointing,or even embarrassing to the student.

Research studies demonstrate that somestudents who are D/HH have difficulty acquir-ing age-appropriate syntactic skills (Cannon& Kirby, 2013; Ganek, McConkey Robbins,& Niparko, 2012; Moeller et al., 2007). Mor-phological markers such as plural -s or tensemarkers such as -ed and -ing consist of high-frequency consonants and rely on adequateauditory access and auditory skills. As a re-sult, syntactic development could be an area

in which students might require interventionfor a longer duration than they might in vo-cabulary or pragmatics (Ganek et al., 2012;Moeller et al., 2007). Difficulty with com-prehension or expression of complex syntaxin spoken language can translate into diffi-culty in reading or writing texts containingsophisticated language. Consider the follow-ing prompt to write an alternate ending tothe story, for example, “What else could Cadehave done to solve the problem of the miss-ing birthday present?” Student responses re-quire the understanding of highly complexlanguage, including the modal of possibility(could) and perfect tense (have done) tocommunicate something that did not hap-pen but could possibly have happened in anew ending. One resource that can assist thepractitioner in implementing intervention forsyntactic development in a systematic man-ner is the Cottage Acquisition Scales for Lis-tening, Language, and Speech (CASLLS). Formore information about this resource, seeSupplemental Digital Content A (available at:http://links.lww.com/TLD/A59).

Literacy development and intervention

In addition to developing vocabulary andcomplex language, students who are D/HHneed direct instruction in phonological aware-ness, phonics, morphological awareness,sight word reading, and related concepts. In-struction and intervention related to readingand writing are a broad topic, which is beyondthe scope of this article focusing on princi-ples of LSL intervention. Gross and Robertson(2017) provide a detailed overview of literacydevelopment of students who are D/HH. Athorough discussion of literacy interventionsfor students who are D/HH can be found inRobertson (2014). In addition, in this specialissue, Alfano and Douglas (2018) discuss lan-guage and literacy development for childrenwho are bilingual.

Special considerations for studentswho are D/HH and EL

A recent review of guidelines for ac-commodating to the needs of ELs in the




elementary classroom yields a list of tips that,not surprisingly, parallels many of the samestrategies recommended for students who areD/HH in the mainstream. These recommen-dations include general instructional princi-ples, specific linguistic guidelines addressingvocabulary, syntax, and nonliteral language,as well as delivery of instruction.

Whether students are D/HH, ELs, or both,one important suggestion is to consider theinterplay between the content and languageused to convey important subject matter con-cepts. During classroom instruction, inabil-ity to derive the correct meaning from acomplex sentence can limit comprehension.For example, consider the following sentencethat might be found in a science text de-scribing erosional effects and the compre-hension skills necessary for understandingthe language: “Repeated swings in tempera-ture can also weaken and eventually fragmentrock, which expands when hot and shrinkswhen cold.” Although concepts included inthis sentence may be within the cognitive ca-pacity of the student, unfamiliar vocabularyand the grammatical structure may mask itscomprehensibility. It stands to reason, then,that when subject matter is newly presented,preteaching of the vocabulary and simplifica-tion of the grammatical frame may assist astudent in grasping the essence of the corecontent.

One recommendation for practitionersworking with students in classroom who areD/HH is to follow the EL guidelines offered inTeacher’s Guide for a particular academic sub-ject. In addition to the precise content vocab-ulary specified by the topic under study, thereare many Tier 2 vocabulary words that appearin text with the assumption that they are al-ready present in the lexicon of the typical stu-dent. Seemingly innocent words such as in-dividual, regularly, separate, and constantmay be found as modifiers to subject matterwords but may be virtually meaningless to anEL student who is D/HH who then overlooksthe important information such words con-tribute to understanding the text. The highutility of knowing such words makes them

worthy targets for intervention; thus, the prac-titioner may wish to consider the role ofwords such as these as part of a total languageplan. Similarities between recommendationsfor students who are D/HH and are ELs areapparent in Table 1.

In summary, hearing loss influences howa child learns to listen, speak, read, andwrite. Facilitating the development of age- andgrade-appropriate language and literacy skillsbegins with early intervention but continuesthroughout the school years so that the stu-dent will be college or career ready. Thus, allinterventions provided to students who areD/HH or D/HH and EL by any member of theinterprofessional team are rooted in and fosterthe growth of listening, language, and literacy.

Principle 3: Intervention isindividualized, systematic,and richly multidimensional

Teachers and therapists who are creatinglearning objectives for IEPs and providing in-tervention to students who are D/HH in aschool setting take into account the child’shearing history, auditory access, and homelanguage and present levels of performance inlanguage, literacy, and other academic areas.Whereas the first two principles focus on thewhat and why of LSL intervention, this thirdprinciple focuses on the how. That is, inter-vention should be individualized to thestudent’s unique learning profile and desiredoutcomes, utilizing a systematic approachthat takes into account a hierarchy of skill de-velopment in language, literacy, and academicareas, and is richly multidimensional soas to target objectives from multiple domainswithin the same activity or lesson.

Individualized intervention

When working with a student who mightbe on a Keep Up, Catch Up, or Move Uptrajectory, practitioners are charged to iden-tify challenging but achievable goals acrossall domains of knowledge and skill building.Goals and activities that take into considera-tion child-specific factors of hearing and learn-ing create the desirable difficulties that make



Table 1. Comparison of teacher recommendations for students who are D/HH and studentswho are ELs

Domain Students Who Are D/HH Students Who Are ELs

General instruction Weigh cognitive load againstlinguistic density

Balance content and language

Teacher–studentinstructional turns

Provide wait time for processingof teacher question

Offer opportunities for spokenlanguage practice

Assessingcomprehension

Ask student to repeat orsummarize the lesson withrandom checks of all studentsso as not to target the studentwho is D/HH

Check for understanding byasking the student to tell howhe or she will approach anassignment

Vocabulary Consider lesson previewhighlighting unfamiliar words

Encourage word learning,especially in context

Languagestructure/syntax

Build receptive languageunderstanding and transfer toexpressive output

Provide a language model andrecast for syntactic complexity

Nonliteral language Be on the lookout for idiomaticlanguage and probe for thestudent’s understanding

Make figurative language explicit

Speed and prosodyof speech

Speak slowly and clearly; useacoustic highlighting

Don’t speak too fast; emphasizeimportant concepts

Note. D/HH = deaf or hard of hearing, EL = English learner. Recommendations for students who are D/HH can be foundat https://successforkidswithhearingloss.com/for-professionals/teacher-tips/. Recommendations for students who areELs can be found at http://www.scilearn.com/blog/top-10-tips-for-working-with-ell-students.

true accomplishment motivating for the stu-dent. In so doing, any child has the opportu-nity to develop what Dweck referred to as agrowth mind-set as opposed to a fixed mind-set (Dweck, 2007). In the former, childrenadopt a “can do” attitude and celebrate effortand the achievement that come from thought-ful strategy selection and steady progress to-ward a goal. Without question, this is an im-portant disposition to learning for all children,especially those who are D/HH. When goalsof intervention are targeted for students whoare D/HH as individuals, following the mile-stones of development in a systematic man-ner, and customized to place learning wellwithin the zone of proximal development(Vygotsky, 1978), it is more likely to ensurethe success that serves as the motivation forcontinuing to “do hard things.”

Typically, students who are receiving LSLintervention have deficits in some but not all

domains. Consider the following scenario ofa 5-year-old kindergartener, Ruby, who is ona Move Up trajectory.

Ruby has only recently begun using bilateralcochlear implants and has substantial needs in thedomains of audition, speech, and language. Shedemonstrates age-appropriate cognitive and motorskills. As her classmates learn about various animalhabitats, Ruby is learning the names of animals.As detailed by Rosenzweig (2011), when there isa big difference in chronological age and hear-ing age, providers must consider age-appropriatelearning activities, even though the targeted audi-tory and/or language goals may be rudimentary.Ruby might benefit from learning names of ani-mals (a stage-appropriate skill) through dramaticplay (an age-appropriate activity) facilitated by theprovider within the general education setting dur-ing a “push-in” session. Similarly, in an individualintervention session, Ruby could continue to learnanimal names through reading a book such as DearZoo or singing Old McDonald Had a Farm.


https://successforkidswithhearingloss.com/for-professionals/teacher-tips/

http://www.scilearn.com/blog/top-10-tips-for-working-with-ell-students


Given the reality of scheduling constraintsin a school setting, it is often incumbent uponthe providers to deliver intervention in smallgroup settings. We propose that it is possi-ble to provide individualized LSL interventioneven when working with children who are atdifferent ages and stages in development. Forexample, Ruby could be paired with her class-mate Ishan, who is on a Catch Up trajectory.Ishan’s language goals include expanding vo-cabulary and increasing syntactic complexity.In keeping with the animal habitat theme,while looking through a picture book, theprovider could ask Ruby, “Where is the pig?”and then ask Ishan, “Where does it live?” withthe expected response of “the pig lives in thesty.” In this scenario, both students are receiv-ing targeted intervention, even though theyhave different language goals. In addition,there is an opportunity to work on social skillsas well as literacy skills through dialogic read-ing (DesJardin & Ambrose, 2010; DesJardin,Ambrose, & Eisenberg, 2009; DesJardin et al.,2017).

Systematic intervention

In addition to developing individualized in-tervention, it is important to contextualizeselected targets within a hierarchy of devel-opment. For example, 6-year-old Vincent hasprogressed from “want apple” to “I want anapple” to “May I have the big, red apple?” Thenext step in his syntactic development couldbe the use of relative clauses and prepositionalphrases, for example, “May I have the big, redapple that is on the counter?” Note that inaddition to development of complex syntax,the provider has to work on developing a vari-ety of syntactic elements, for example, prepo-sitions to be used in prepositional phrases,starting from early emerging prepositions, inor on, to the next level of beside or above.Attention to systematic progression of skillsis also relevant for audition, vocabulary, liter-acy, cognition, and even social skills develop-ment. For more information on resources, seeSupplemental Digital Content A (available at:http://links.lww.com/TLD/A59).

Richly multidimensional intervention

For most students who are D/HH, practi-tioners must keep up with academic contentwhile backfilling the idiosyncratic holes in lin-guistic, auditory, and critical thinking skills.With the focus on closing the language gap,it is not feasible to target only one objectivein one lesson. There is an economy of es-sential function when each of the student’sneeds is considered in a rich interventionalplan that targets many objectives in a single,well-designed session.

For example, it is possible to include audi-tory, receptive, and expressive language (in-cluding form, content, and use) targets in sev-eral activities within a session. For example,as a companion to a classroom unit on theenvironment, a student who is D/HH may beasked to categorize items as being recyclableor not when given an auditory-only presenta-tion of a list, recall the sequence of events out-lined in a trade book about one town’s effortsto recycle, and create a television commercialthat promotes recycling. Each of these activi-ties targets listening, language, and vocabularyobjectives as well as writing and pragmaticgoals that are embedded into this content-related and theme-based LSL intervention. Forthe practitioner who is classroom-based, thereare resources within the Teacher’s Guide ofmost curricula that can be consulted to assistin planning functional intervention that meetsthe needs of students who are D/HH and whoalso are ELs.

Principle 4: Effective intervention isdriven by interprofessional practice

Recall that only a limited number ofteachers and SLPs have specialized training inworking with students who are D/HH and useLSL, perhaps related to the fact that studentswho are D/HH are part of a low-incidencepopulation. Within the last decade, morepractitioners have been able to obtain a post-graduate certificate as a Listening and SpokenLanguage Specialist Certified Auditory VerbalTherapist or Educator (LSLS Cert AVT or CertAVEd) through the Alexander Graham Bell




Academy for Listening and Spoken Language(www.agbell.org/teach).

Currently, there are approximately 800 cer-tified LSLSs worldwide. A majority of thesepractitioners reside in the United States andprovide intervention in English (Guignard,2017). Of these practitioners, 43% are teach-ers of students who are D/HH and 39% areSLPs. Most are intersecting with students whoare D/HH and/or ELs in public schools, privatespecial education programs, or private prac-tices. The LSLS designations indicate that theindividuals who have earned them have expe-rience and expertise in developing LSL skillsin students who are D/HH. They have com-pleted a rigorous certification process that in-cludes 900 hr of practice, continuing educa-tion, mentoring with an established LSLS, andknowledge and skills examination.

In the absence of this specially certified in-dividual, it is well within the scope of practicefor SLPs to address the needs of the school-aged population of students who are D/HH.Given a strong base in language acquisition, anunderstanding of the importance of auditoryaccess, and a keen awareness of the linguis-tic challenges and hazards that face studentswho are D/HH, SLPs who are knowledgeable,skilled, and inquisitive can and do supportthe established trajectory of learning of thesestudents.

Building the team

Interprofessional teams are formed and re-formed depending on the abilities and needsof the individual students for whom they areassembled. It might be suggested, then, thatthe makeup of any particular interprofessionalteam is driven by the specific profile of the stu-dent who is D/HH. Students presenting with aKeep Up profile might need a small team, forexample, an audiologist, a classroom teacher,and an SLP (bilingual or monolingual if thresh-olds for qualifications for services are met). Insome cases, however, even a student with age-appropriate language and literacy skills mightneed a team with additional personnel, suchas an itinerant teacher of students who areD/HH, a captioner, a notetaker, or perhaps

even an educational (sign) interpreter to as-sist in providing access to higher level cur-ricular instruction. Catch Up students mightrequire these same personnel, but the teamcould also include a reading specialist and abilingual education specialist to meet the stu-dent’s individual learning needs. As anotherexample, students presenting with a MoveUp profile may require a team that goes wellbeyond the core members indicated earlier.For such students, additional team membersmight include a neurologist, a special edu-cation teacher, an occupational therapist, aschool psychologist, and perhaps a vision spe-cialist to help meet the student’s multiplelearning challenges.

Working as a team

Today’s interprofessional collaborative pra-ctice guidelines state explicitly that providersand families/caregivers work together to im-prove outcomes and quality of care and edu-cation of their students. According to ASHA(2017), IPP occurs when multiple serviceproviders from different professional back-grounds provide comprehensive educationalservices by working with individuals and theirfamilies, caregivers, and communities to de-liver the highest quality of intervention acrosssettings. The tenets of IPP would suggest thateach team member has a designated contri-bution to make with regard to the needs ofstudents who are D/HH and might also beELs. This means that attitudes of professionalcentrism are discouraged to avoid scenarios inwhich one team member assumes greater im-portance than the others (Pecukonis, Doyle,& Bliss, 2008). Interprofessional practice callsfor a more conscious and focused effort asa team member in which each individual isresponsible for bringing integrity, commit-ment, engagement, and effort to the team.Blaiser and Nevins (2017) acknowledged theself-work that is needed to become a con-tributing team member and offered practicalsuggestions for the IPP team members whowork with students who are D/HH. They cau-tioned against waiting for scheduled IEP meet-ings to be the impetus for communicating,


www.agbell.org/teach


suggesting that these formal meeting were es-sentially insensitive to a need for discussionsregarding hearing fluctuation or variable lan-guage performance as a function of variouslistening environments at school (classroom,cafeteria, gymnasium, therapy room). Theyurged the use of both formal and infor-mal communication strategies (e.g., check-lists, forms, e-mail, or notebooks) to keepteam members apprised of student progress.Unique situations may also call for a recast ofmore traditional team members.

Consider the following scenario of a middleschool student, Estuardo, who is on a Keep Uptrajectory:

Estuardo is a bilateral hearing aid user whoseparents are migrant workers and speak Kekchiat home. In elementary school, Estuardo demon-strated the profile of a Keep Up learner. Now inmiddle school, he is struggling with wear time ofhis devices and social acceptance in his classroom.Issues of school avoidance are beginning to appearand general withdrawal behaviors are becoming anincreasing concern. No one member of his currentteam is capable of addressing the multiplicity ofhis needs. Inviting a school counselor, school psy-chologist, or an EL teacher to join the team andcollaborate to identify child- and family-focused so-lutions seem to be the most direct path to redirecthim to his previously promising learning trajectory.

Principle 5: Families are included andempowered to be partners in listening,spoken language, and literacydevelopment

Given the fact that Universal NewbornHearing Screening makes it possible to screenfor hearing loss in children, identification ofhearing loss in the first few weeks and monthsof life has become imminently achievable. Inturn, early identification opens the door forfamilies to play an integral role in their child’sLSL development. Families are nurtured in fo-cused intervention in which they play a promi-nent role and develop a disposition to inclu-sion and active participation as their child’sfirst teachers. To continue this early relation-ship with families through the preschool, el-ementary, and high school years makes good

sense for all involved, especially the studentwho is D/HH.

That said, families who might not have hadaccess to practitioners who speak their pre-ferred language face an additional challengeof understanding the information supportingearly LSL development of their child in or-der to enhance their knowledge and skills.Cultural differences that are not understoodby practitioners may pose an additional bar-rier. If this has been the case, it would notbe surprising to discover idiosyncratic gaps infamilies’ understanding of hearing loss, its ef-fect on language learning, and familiarity andcomfort with the strategies and techniques forLSL development. Furthermore, if congenitalhearing loss is not identified until after theearly intervention years, there will be a lossof not only critical learning time for the childbut also dedicated time for family learning.As a factor in long-term outcomes, effects ofmissing the early intervention period are com-pounded over the years and influence achieve-ment of a personal best that might never berealized with a different timeline.

When appropriately enacted, family-centered intervention engages the adultfamily members and facilitates and coachestheir development of the knowledge andskills that foster language learning for theirchild. All too often, once the child begins toattend school, the focus shifts to teacherstaking on the responsibility of teachingand providing intervention, with familiesfunctioning on the periphery and makingsure that the student completes his or herhomework. Studies that have examined thecontribution of family involvement in thepreschool and school years for studentswho are D/HH have concluded that it is astrong predictor of language proficiency andacademic achievement (Boons et al., 2012;Reed, Antia, & Kreimeyer, 2008).

Role of family

Many families of students who are D/HHhave been coached during the early in-tervention years to create a language-richenvironment and engage in meaningful



interactions with their child. In that period,efforts are focused on establishing consis-tent use of hearing technology, acquiring firstwords and sentences, and enjoying sharedbook reading. Families require similar supportand coaching if students begin to question thevalue of their hearing technology or strugglewith mastery of higher level auditory skills,Tier 2 and academic vocabulary, increasinglycomplex syntax, or challenging reading andsubject matter assignments. When familiesunderstand the strategies that practitionersare using, they can support the child’s learn-ing beyond the classroom environment andinto real-world experiential learning. Talkingaloud about nuances in conversations, ex-plaining social conventions, and the linguis-tic choices that are made in exchanges in thelarger community can be quite instructional.This explicit instruction provided by the fam-ily can build confidence in conversation initia-tion and participation within the community.

When the language of instruction in schoolis provided only in English or mostly in En-glish, the responsibility for the developmentof increasing sophistication in the home orheritage language becomes the purview ofthe family. Because culture and heritage lan-guage are inextricably linked, families can beencouraged to develop advanced home lan-guage capacity that will allow their studentwho is D/HH to appreciate stories associatedwith familial and cultural heritage and to be afull participant in family life. Especially impor-tant are the language and vocabulary that iden-tify and describe the kinship relationships thestudents have beyond the nuclear family. Asa counterpart to advancing English languageskills, understanding of and appreciation foridiomatic expressions that have meaning inthe context of the home language can supportparticipation in communicative exchanges athome.

As students move through the elementaryyears, families also may choose to revisit goalsthey set while their child was still in the earlyphase of intervention and reconsider whetherthose goals continue to be applicable/reachable as the student ages. Are the Keep

Up students still keeping up? Is college or uni-versity attendance on the horizon? If so, whatis the transition plan to make that goal a re-ality? How can families assist their student tocontinue to reach personal best? Other typesof postsecondary education might be consid-ered for the Catch Up student, who despitehis or her best efforts still struggles with therigors of an academic track. With socially com-petent linguistic skills, there are many optionsfor postsecondary endeavors for the studentswho demonstrate this profile of potential andfamilies may need support as they make ap-propriate adjustments to their previous de-sired outcomes for their child. For families ofstudents who continue to progress on a MoveUp trajectory in their later years of school-ing, realistic, potentially difficult choices mayneed to be made to prepare the studentfor adult life. Success for students in thelater years of their educational journey be-comes increasingly idiosyncratically defined.Practitioners who work with these students(and their families) must be sensitive to theemotional ramifications of reaching the endof the traditional K-12 period and be preparedto have frank conversations that will driveIEP/transition plans.

Finally, families who have long advocatedfor their children who are D/HH to getneeded services and supports may find itdifficult to relinquish this important role totheir children. But the long-term benefits forbuilding self-advocacy dictates that it mustbecome part of the IEP for students who areD/HH. With self-advocacy as an explicitlystated IEP goal, students can develop theconfidence, as well as the language, toadvocate for themselves. Nevins and Chute(2018) have suggested that students must beable to make requests that help getting theiraccess needs met. For example, one requestmight be for other students in the classroomto pass around a microphone that transmitsdirectly to the student’s hearing device duringdiscussions so that the student who is D/HHhas an opportunity to hear every student’scontribution firsthand. Asking a teacherto repeat a question, a spelling word, or



homework assignment may be necessarymore than once per day; knowing howto pose these requests in a manner theteacher can accept is an important ancillaryto the academic curriculum and successfulparticipation in the mainstream classroom.Self-advocacy statements that are commu-nicated in a clear and nonconfrontationalmanner can have greater pragmatic accep-tance than a first salvo that is demandingor complaining. Command of the language,vocabulary, and social signals required to beclear in communicating advocacy needs iscrucial and may be included as importantintervention goals for any student who isD/HH. For more information about resourcesfor self-advocacy development, see Sup-plemental Digital Content A (available at:http://links.lww.com/TLD/A59).

CONCLUSIONS

The five principles of LSL intervention thatare presented in this article are meant to in-form the practitioner in the development oflistening, language, and literacy skills in asystematic manner that meets the individualneeds of each student who is D/HH or D/HHand EL. An interprofessional team working incollaboration with the families can help stu-dents achieve their personal best. Resources

such as those presented in this article (in-cluding the Supplemental Digital Content A,available at: http://links.lww.com/TLD/A59)and associated articles in this issue of Top-ics in Language Disorders are offered topractitioners to guide intervention and sus-tain advances made in a child’s early languagejourney.

As indicated previously, outcomes of stu-dents who are D/HH or D/HH and EL areinfluenced by a number of extrinsic factorsover which there is a degree of control. En-suring quality service provision to address thehighest priority needs of these students iswell within the reach of teachers and SLPscommitted to mindful practice. These prin-ciples and practices are based on the cur-rent state of knowledge in the field. We ex-pect that advances in hearing technology,early intervention, and new findings from lan-guage and brain research, especially thoserelated to bilingual acquisition, will lead toan expanded set of principles and practicesin the near future. We urge practitioners tostay fully engaged in the field and expandtheir knowledge related to the developmentof LSL. Through ongoing professional learn-ing, practitioners can continue to refine theskills needed to assist students who are D/HHor D/HH and EL in keeping up, catching up, ormoving up.

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