Sometimes it is difficult to tell whether or not a child with a hearing loss is presenting with a true speech and/or language disorder, or if the problems in their speech and language skills are due to hearing loss alone. For some children, you think, “Wow. This child probably would have had speech/language issues even without his hearing loss!” For example, some speech and language problems, like fluency disorders (i.e. stuttering), have a strong genetic component. But other times, you think, “Does this child really have speech and language problems, or is she just delayed because of inadequate access to hearing?” These two theories require very different therapeutic approaches. For a child with a true speech and language issue, like apraxia, that is unrelated to his or her deafness, a more traditional “speech therapy” approach may be in order. For the latter group of children (in my opinion, the majority of children with HL), the goal should be to give the child more access to sound, and more listening and spoken language training, to allow them to develop these skills — a developmental, acoustic approach, not a remedial, visual plan. But where do you draw the line? How do you decide the “cause” of these invisible, ever-changing delays or disorders, especially when so many children with hearing loss are not “just deaf” and often have a multitude of complicating factors?
Well, the literature and common sense offer some starting points for how we can consider these issues.
First, as always, it’s very important to remember that children SAY what they HEAR. If the child is not receiving access to sound, his or her speech is going to be impacted because of it. If you have typical hearing, think about when you get off of a plane or have a cold and your ears are stopped up. Do you feel self-conscious or worry that your voice is nasally, too loud, or too soft? I know I do! That’s because we constantly monitor our own speech through the auditory feedback loop — you hear what you say, and make adjustments accordingly when you hear that you’ve pronounced something wrong, or at the wrong volume, etc. For deaf children whose parents have chosen listening and spoken language, the goal is that they will be able to do the same. For them, as for people with typical hearing, the best possible access to sound is crucial for self-monitoring.
For children with hearing aids, no matter how good and well-programmed they are, the high frequencies that distinguish some speech sounds may still be inaudible. If a child is suspected of having a “language disorder” because he omits the plural “-s” (cats) or possessive “-’s” (Matt’s) or third-person singular (walks), could it be that he just cannot hear the high-frequency components of the /s/ sound and so he’s not language disordered, he’s just saying what he hears? Same would go for /f/, /?/ (“sh” as in shoe), or /?/ (“th” as in thumb).
Ling (2002) lists the following “Examples of Speech Patterns stemming from Inadequate Perception that Were Often Confused with Phonologic Process”
Substitution (switching sounds, putting an incorrect sound in the place of the correct sound)
De-affrication (not saying affricate sounds, like saying “dump” for “jump,” where “j” is the affricate sound)
Omission or stopping of fricatives (for the fricative “f” as in fun, the child either omits “-un” or adds a stop sound “pun”)
Weak syllable reduction (leaving out unstressed syllables — “nana” for “banana”)
Cluster reduction (leaving out parts of a cluster, or “blend” — like “tar” for “star”)
Stridency deletion (“noisy” sounds like “ch, j, sh, z” are either left out or replaced, so “chair” becomes “air” or “tair”)
Liquid Simplification (liquids are /r/ and /l/, child would say “w” for /r/, so “wake” for “rake”, and/or “y” for “l”, so “yook” for “look”)
So what does that mean in English, please? Basically, what Ling is saying is that these patterns, which would commonly be treated by a general SLP in a very, “put your tongue like this and lips like this, let’s look in the mirror and see how it looks”-type approach, in children with hearing loss, we should try to optimize HEARING first, and help the children attain more normal, natural speech and language patterns through AUDITION alone, before introducing more traditional visual/tactile methods. (For children with typical hearing, the general SLP’s approach may be entirely appropriate. These children have the benefit of an intact auditory system, and really may need some visual supports. For a child who has experienced auditory deprivation, however, we must try to build their auditory brain first and foremost, to establish the neural connections that will benefit them for the rest of their lives!)