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Deaf Education: The Impact of Cochlear Implantation?



This paper reviews the impact that cochlear implantation has had on the practice of deaf education in terms of educational placement, communication choices, and educational attainments. Although there is variation in outcome, more children with implants are going to mainstream schools, and using spoken language as their primary means of communication, and the evidence to date suggests that cochlear implantation early in life has led to improved levels of spoken language and educational attainments. However, there is also evidence that providing an appropriate educational environment for these learners remains a challenge – from parents making choices in the early years to students managing the complexity of the secondary and post-secondary setting. Managing the technology effectively in the classroom remains an issue in many schools, and ongoing training of teachers and other educational workers needs to include its management. While the positive benefits of cochlear implantation are clear, we must also be mindful of the attendant challenges in providing flexibility of choice in meeting the needs of this increasingly diverse population.
Deaf Education: The Impact of Cochlear
Sue Archbold
The Ear Foundation, Nottingham, UK
Connie Mayer
York University, Toronto, Canada
This paper reviews the impact that cochlear implantation has had on the prac-
tice of deaf education in terms of educational placement, communication
choices, and educational attainments. Although there is variation in
outcome, more children with implants are going to mainstream schools,
and using spoken language as their primary means of communication, and
the evidence to date suggests that cochlear implantation early in life has led
to improved levels of spoken language and educational attainments.
However, there is also evidence that providing an appropriate educational
environment for these learners remains a challenge from parents making
choices in the early years to students managing the complexity of the second-
ary and post-secondary setting. Managing the technology effectively in the
classroom remains an issue in many schools, and ongoing training of teachers
and other educational workers needs to include its management. While the
positive benefits of cochlear implantation are clear, we must also be mindful
of the attendant challenges in providing flexibility of choice in meeting the
needs of this increasingly diverse population.
keywords cochlear implantation, deaf children, deaf education
Cochlear implantation, in providing useful hearing across the speech frequencies for
profoundly deaf children for the first time, is having an educational impact in ways
that no changes in pedagogy or communication approach have previously achieved
(Archbold, 2010; Mayer & Leigh, 2010). In this paper, we will consider the nature
of this educational impact from the perspective of change. We will review some of
the major studies in the area and describe shifts in educational placement,
deafness & education international, Vol. 14 No. 1, March, 2012, 215
© W.S. Maney & Son Ltd 2012 DOI 10.1179/1557069X12Y.0000000003
communication choice, educational attainment, and parental/student perspectives.
We will conclude by summarizing the implications of these changes for educational
policy and practice and teacher training in the era of the cochlear implantation.
Impact of cochlear implantation on educational decisions
The educational management of deaf children has long been controversial, often with
little evidence to support practice and ideology. In part this is due to the fact that deaf
children and young people are a challenging group for researchers to consider. They
are a particularly heterogeneous population with many variables to account for,
including aetiology, age at diagnosis and amplification, cognitive ability, socio-
economic status, parental support, communication preference, and educational
history. Cochlear implantation has added yet more variables: age at implantation,
type of implant, pre-implant hearing levels, processing strategy, and programming/
management of the system. Defining homogeneous groups in order to implement tra-
ditional research methodologies may be appealing, but does not represent the popu-
lation that educators work with, and it is unlikely to produce research that will
influence educational policy and practice in a meaningful way (Leigh, 2008; Arch-
bold, 2010). However, there is a tendency to view children with cochlear implants
in this way. Cochlear implantation, set in a medical and surgical context, has been
the subject of a great deal of research (for a discussion see Thoutenhoofd et al.,
2005), and, 20 years on, there are numerous studies that have explored the impact
of cochlear implantation on language development, educational attainments, and
the educational decisions of placement and communication choices.
Cochlear implantation and educational placement
In step with a world-wide movement to inclusion and the education of all children
with a disability in a mainstream setting, children with cochlear implants are increas-
ingly being educated in mainstream schools (Uziel et al., 2007; Geers et al., 2008;
De Raeve et al., 2012), even when compared to those children using hearing aids
(Archbold et al., 2002). This shift in educational placement has brought with it a
new set of issues, particularly in the later years. When questioned about their experi-
ences of being mainstreamed in a secondary school setting, young people, their
parents and teachers described the challenges of handling increasingly complex
language and concepts, poor acoustic conditions, greater number of teachers and
teaching styles, and the increased use of group work (Wheeler et al., 2007; RNID,
2008). These combine to make access to the curriculum and classroom language
increasingly difficult. Additionally, the excellent levels of speech intelligibility typi-
cally achieved by those implanted early may mask the young persons language
delay or difficulty in the more subtle pragmatic communication skills required in
the classroom, particularly at the high school level.
Damen et al. (2006, 2007) investigated the performance of children with cochlear
implants in mainstream classrooms using the assessment of mainstream
performance (AMP; Chute & Nevins, 2006) and the screening instrument for target-
ing educational risk (SIFTER: Anderson, 1989) to compare them with their hearing
peers. Their studies revealed a wide variation in functioning, and although the results
are encouraging, the group using cochlear implants scored significantly less well than
their normal-hearing peers on areas of both the AMP and the SIFTER. The most
important variables impacting on the outcomes in this study were age at implantation
and duration of deafness. Mukari et al. (2007) also used the SIFTER, and found that
children with implants were rated poorly in the communication assessments. They
conclude that children with implants continue to need specialist support in main-
stream classes, and that linguistic delay may be one of the causes, in spite of the
levels of hearing provided by the implant. When interviewed, young people reported
that listening in groups and noise in school was extremely challenging, and resulted in
missing important parts of the lessons or instructions (RNID, 2008).
Cochlear implantation and communication mode
In addition to educational setting, the other major educational decision made relates
to communication mode. Oral communication has often been linked with improved
outcomes from implantation (Geers et al., 2003, 2011; Geers, 2006; Spencer &
Oleson, 2008; Wiefferink et al., 2008). In the large-scale study Geers et al. (2011)
reported that of 112 adolescent users of cochlear implants, those who relied on
spoken language at an elementary level evidenced higher levels of language and lit-
eracy at high school.
Studies comparing outcomes from implantation in children using oral communi-
cation and those using signed communication often suggest that communication
choice is a once and for alldecision, that communication does not change over
time, or that differing communication modes may be used in differing situations.
However, children with cochlear implants do change communication mode after
implantation, particularly if implanted early (Watson et al., 2006; Tait et al.,
2007). Parents were asked if their child had changed communication mode follow-
ing implantation, and if so, how and why (Watson et al., 2007). The trend was mark-
edly towards an increase in oral communication, even for children who had initially
used signed communication. Parentsviews were that this shift was largely driven by
the change in access to audition provided by the implant and was led by the childs
changing needs and own choice. Those implanted younger were more likely to
change communication mode from sign to oral and did so more quickly than
those implanted later, with 83 per cent of those implanted below the age of three
using oral communication exclusively 5 years after implantation. In another
study, the majority of those implanted at one moved from signed communication
to oral within 6 months of implantation (Tait et al., 2007).
In interviews parents have described this as a communication journey (Wheeler
et al., 2009). While clearly the goal of cochlear implantation for parents was the
development of spoken language, parents were also pragmatic about the
communication that was crucial to family life. Prior to implantation they wanted the
most effective form of communication, which, for hearing families who make up 95
per cent of parents of deaf children, was likely to be a spoken language, with or
without some signed or gestural support. Following implantation parents reported
a reduction of signed support as spoken language developed through increasing
access to audition via an effective implant system. Later, parents and young
people showed interest in the use of some signed support or Sign Language (e.g.
BSL) itself, once spoken language had been established. Thus, while cochlear
implantation offers increased opportunity for the development of oral communi-
cation, parents recognize that differing approaches may be appropriate at differing
times, and this might include the use of signed communication. The concept that
parents have to make a once and for alldecision about communication mode,
shortly after diagnosis, may have been changed by cochlear implantation: while
cochlear implantation may have brought about new opportunities for spoken
language, the decision may not be as clear cut as once was predicted.
However, obtaining appropriate provision and flexibility in educational services
has often been a source of tension between parents and local teachers (Sorkin &
Zwolan, 2004; Sach & Whynes, 2005; Wheeler et al., 2008). Sach and Whynes
reported that parents had to fightfor the provision they felt appropriate for their
child, and Sorkin and Zwolan found that 30 per cent of parents described being
unable to obtain the educational provision they wished for their child.
Cochlear implantation and educational attainments
It has become standard practice to compare the educational progress of children
with implants to that of normally hearing children. This was not as common
prior to implantation, and is significant in considering the educational implications
of cochlear implantation. Comparison to (and achieving) age appropriate outcomes
has become the new benchmark. For example, Dettman et al. (2007) looked at nine-
teen infants implanted below age of one (mean age at implant 0.88) and found that
language growth was significantly greater in these infants than in a matched group
implanted between 12 and 24 months. Their growth rates matched the growth rates
of normally hearing infants. Nicholas and Geers (2007) used the Pre-School
Language Scales with 76 children aged 3.5 and 4.5 years of age, implanted below
the age of three. They found that those implanted between 12 and 16 months
were more likely to achieve age-appropriate spoken language. Ching et al. (2008)
reported that children implanted below the age of 12 months developed normal
language skills at a rate comparable to hearing children. Tait et al. (2007) compared
the pre-verbal communication skills of children implanted before the age of one,
with normally hearing children. They found that normally hearing children pro-
gressed faster, but the difference was not significant.
Investigation into educational attainments following implantation is still in its
infancy, given the long time frame from implantation to school entry to graduation.
That said, early reports are encouraging with studies to date focusing primarily on
reading outcomes. A review of reading studies by Marschark et al. (2007) reported
improved reading skills in those with implants, but not on a par with their hearing
peers. Archbold et al. (2008a) found that age at implantation was a significant factor
in the development of reading skills. Those children implanted before the age of 42
months, and with a non-verbal IQ in the normal range, had age-appropriate reading
scores both 5 and 7 years after implantation. In their study of fifty deaf children
with at least 3 years of implant use, Vermeulen et al. (2007) found that those with
implants had significantly better reading comprehension scores than those with
hearing aids, but remained substantially behind hearing peers. Other researchers
(Geers et al., 2003, 2008, 2011; Spencer et al., 2003; Spencer & Oleson, 2008)
have also reported encouraging reading results in children after implantation.
However, it is still an open question as to whether these encouraging results hold
as the children move into adolescence, with the more demanding and subtle skills
required to achieve age-appropriate reading levels (e.g. inferencing). In spite of
reports of age appropriate language development in early implanted children
(Ching et al., 2008; Dettman et al., 2007), reports of progress in educational attain-
ments in the longer term are more cautious. Geers et al. (2008) reported long-term
outcomes from a large study of children implanted in the pre-school years. When
assessed at ages 8/9 years, reading levels were within normal levels. However,
when retested at ages 15/16, while speech perception scores improved over the
long term, and average language scores improved at a faster than normal rate,
reading scores did not keep pace over time. They concluded that early cochlear
implantation impacted positively on auditory and verbal development in the
group of eighty-five adolescents they tested, but age-appropriate reading levels in
high school were not found for the majority of students. In a further study, Geers
and Hayes (2011) also reported that there were significant delays in spelling and
written expression in their group of 112 adolescents compared with hearing
peers. Harris and Terlektsi (2010) compared the reading skills of a group of 12
16 year olds with implants with those with hearing aids, and found that the
reading ages of all groups were several years below that of their hearing peers.
Thoutenhoofd (2006) in his study of deaf children in Scotland showed that those
with implants had better educational attainments, particularly in mathematics, than
those with hearing aids, but scored more poorly than their hearing peers. Stacey
et al. (2006), in an investigation of a large group of cochlear implant users in the
UK, found paediatric cochlear implantation to be associated with reported improve-
ments in some aspects of educational achievements and quality of life, provided that
children receive implants before 5 years of age.
Cochlear implantation and parent/student perspectives
Parents reported that implantation had influenced their educational decisions, sup-
porting a move towards spoken language and mainstream provision (Archbold
et al., 2006). Over half of the parents were concerned about their childs future
education, with one-third of parents expressing the opinion that their child was not
keeping up educationally with their hearing peers (Archbold et al., 2008b). Another
major concern for parents was the management of the technology in the classroom.
This is not a new concern: Geers & Moog (1995) pointed out that the long-term
management of cochlear implants resides with teachers.
To get a sense of the student perspective, Wheeler et al. (2007) interviewed twenty-
nine young people with cochlear implants. Their responses indicated a reliance on
the technology, and a dislike of being without it; one young person refused to go
to school if his implant was not working. A majority felt that their implant helped
them understand lessons. The majority of the group interviewed saw themselves
as either deaf and hearing,orasdeaf, recognizing that without their implants
they were deaf. Comments such as some days deaf, some days hearingmay indicate
different levels of functioning in different situations. Identity for these students may
not be a fixed concept; the notion that these young people must see themselves as
deaf or as hearing may be outdated. For most (69 per cent) speech was the chosen
mode of communication, with the others using Sign Supported English. Wheeler
and Archbold (2009) reported that the group appeared pragmatic about choice of
communication mode and were flexible in its use, using signed support or speech
as appropriate. In this group, a positive view of implantation is given, and a flexible
view of communication and identity is reported (see also Wald & Knutson, 2000;
Christiansen & Leigh, 2004; Percy-Smith et al., 2008; Moog et al., 2011).
Variability in outcomes
Outcomes from paediatric implantation have surpassed expectations, even of those
who were sceptical at the outset. The major predictor of positive outcomes appears
to be early implantation (e.g. Dettman et al., 2007; Tait et al., 2007; Archbold et al.,
2008a, b); however, there are some provisos noted in the literature. Holt and Svirsky
(2008) queried whether earliest is always best and found that although earlier
implantation favourably influenced language outcomes, there were few differences
in those implanted before the age of 12 months and those implanted between 13
and 24 months. The advantage in implanting before the age of one was only appar-
ent in receptive language development, not in expressive or word recognition devel-
opment. Leigh (2008) noted that the empirical evidence base for early implantation
is incomplete and equivocal. He challenged studies that do not take account of the
influence of early intervention itself, known to be a positive factor (Yoshinago-Itano,
2004), and which do not highlight the inter-subject variability that is revealed in
many studies where at least some of the later implanted children do well (Svirsky
et al., 2004; Dettman et al., 2007; James et al., 2008).
The other major finding has been that of diversity of outcomes, and the variability
and uncertainty as to predictive factors for positive outcomes (Thoutenhoofd et al.,
2005; Leigh, 2008; Pisoni et al., 2008). Assessment batteries to measure outcomes
following cochlear implantation were often established in cochlear implant centres
and designed to demonstrate benefit and safety in the prevailing climate of contro-
versy. They looked at end points, rather than how the children achieved the goal,
and usually at the childs functioning in the clinic, where some of the variables could
be controlled and where more specific abilities (e.g. listening in differing conditions)
were measured (Archbold, 2010). When looking at outcomes in the home and in
educational settings, the complex interaction of the many influences on progress
increases the likelihood of variability. In addition, cochlear implantation has
increased diversity in an already heterogeneous group. For educators, this variability
combined with the corresponding uncertainty about predictive factors, makes advis-
ing parents about educational decisions and providing appropriate educational
support for deaf children with implants especially challenging.
Cochlear implantation is changing the choices for parents and educators for their
deaf children. It is engendering a shift in the old arguments about communication
choice as profoundly deaf children now have access to spoken language via this
new technology. With very early implantation, communication mode is unlikely
to be well established prior to surgery; the development of effective communication
skills after early diagnosis, combined with early implantation, is likely to bring
together vision and audition in the development of spoken language in a natural
way, as with hearing babies, reducing the need for hearing parents to make a com-
munication choice early in life. Research and practice in this controversial area needs
care in the use of terminology; the use of British Sign Language, with its own
grammar, and without the use of voice, has very different language learning and edu-
cational implications, than that of using Sign Supported English, using English
grammar and simultaneous voicing (Mayer, 2009; Mayer & Leigh, 2010). To
report in research only the comparison of sign and speech masks this. Similarly, edu-
cators, in planning educational provision, must be very clear about their terminol-
ogy and what is provided if the benefits of access to speech through hearing are
to be maximized in the development of spoken language.
Cochlear implantation has also changed educational placement options, with
increased access to mainstream provision, particularly for those implanted early.
However this engenders a new set of considerations. Because learners with cochlear
implants appear to hear well and speak intelligibly, teachers, particularly main-
stream teachers, may fail to realize the impact of profound deafness, even with
the advantage of cochlear implantation, and do not realize studentsneeds,
especially in secondary and post-secondary education (Wheeler et al., 2007;
RNID, 2008). Most children implanted in the past, and the subjects of research
reported here, have only one implant, and the effect of a unilateral hearing loss in
education is well known. Bess et al. (1986) showed that children with a unilateral
hearing loss were ten times more likely to fail a grade, and twice as likely to have
behavioural difficulties, and even a mild, unilateral hearing loss can affect a childs
performance in the classroom (Most, 2004).
Children with implants who evidence intelligible, age-appropriate language are
still not hearing as their hearing peers in the classroom. They are receiving a degraded
auditory signal, and have had a period without auditory stimulation, however early
implanted. They are likely to experience difficulty particularly in noise and in groups,
and are more likely to be dependent on visual clues in order to access language in a
busy mainstream class, and to miss some information or mishear (Hauser &
Marschark, 2008). Their communication needs are likely to be more subtle than
those of profoundly deaf children in the past and easily overlooked. Managing the
rapidly changing technology in the classroom is challenging particularly in the
mainstream classroom with non-specialist teaching staff. Young people and
parents highlighted the reliance of implanted children on the technology, and the
necessity of long-term technical support, with links to the cochlear implant centre.
There are also those who do not do as well as expected prior to implantation and
those with additional needs. Up to 40 per cent of deaf children are likely to have
another difficulty (Fortnum et al., 1996), and are increasingly being considered
for implantation. Prior to implantation, it was difficult to diagnose some additional
difficulties, such as autism, or a language learning difficulty in the presence of pro-
found deafness. Following implantation, some difficulties may be identified which
were not known prior to implantation and for teachers of the deaf, working with
teachers with other specialist areas, such as those working with autistic children,
is now increasingly important.
Cochlear implantation has changed the potential for profoundly deaf children to
increase the level of educational attainments compared to outcomes commonly
accepted in the past. Their language, reading, and other educational outcomes are
now being compared with those of their hearing peers. Evidence does indicate
that their educational attainments are better than their peers with hearing aids,
but not yet as good as those of their hearing peers in the long term. However to
date there is little evidence to show what type or level of educational support
leads to improved educational outcomes for these children.
From parents and young peoplesperspective, education is a major issue and one
where cochlear implantation has made a major impact. While the majority of
parents are satisfied with outcomes from implantation, concerns remain with
respect to certain aspects of education. Parents expressed concerns about the man-
agement of their children into adulthood, and of the technology in the long term.
They wanted local educators to be trained in the management of the technology;
better liaison between implant centres and local educational services; choice and
flexibility in educational provision and communication methodology; and recog-
nition of their childs changing needs and abilities over time. The young people
valued their implants in school, wanted them fully functioning at all times, had a
pragmatic view of communication choices, and generally saw themselves as both
deaf and hearing.
It may be that cochlear implantation demands more of deaf education, rather than
less. Deaf children remain a heterogeneous group; it appears that cochlear implan-
tation has added further to the factors producing variability rather than reducing it.
For educators, cochlear implantation has provided new opportunities, but also new
challenges to address:
Providing flexibility in educational provision over time.
Providing effective support in mainstream, inclusive educational settings.
Supporting a more diverse population with more subtle communication needs.
Monitoring subtle changes in progress over time, and identifying difficulties which
may impede progress, whether these originate in the child, the environment, or in
the technology.
Providing appropriate education for those who have an additional learning
Providing appropriate support for the increasing demands in the secondary,
school setting.
Managing complex, changing technology in a busy educational environment.
Collaborating effectively with a greater number of professionals Providing
peer-group support for the psycho-social needs of the increasing numbers of those
in mainstream settings (Archbold, 2010).
There remains the challenge of long-term management in education for this new
group of children, who are deaf but functioning with levels of hearing provided by
implantation not previously possible for profoundly or severely deaf children, and
who are increasingly using two implants. They are not functioning as profoundly
deaf children of the past, but neither do they function as hearing children. If the
changing needs of this new group of deaf children and young people are to be
met, changing practice needs to be evidence based and to be informed by rigorous
and reliable quantitative and qualitative research (Hauser & Marschark, 2008),
and preferably in the classroom (Archbold, 2010). Such research into the real-
worldfunctioning of deaf pupils should influence service planning and teacher
training as well as the decisions made about appropriate educational support for
individual children.
Implications for teaching and teacher education programmes
As the education of deaf learners has become increasingly complex, teachers of the
deaf are challenged to meet the needs of an increasingly diverse group of learners.
As Leigh (2010) has suggested, there is currently more knowledge and skill
required of a teacher of the deaf than at any time in the history of the field.
Cochlear implantation has served to expand the range of this diversity within the
student population, and of the competencies teachers require in meeting learners
needs. As noted above, this has implications for both teachers and teacher education
For students with cochlear implants, learning is predicated on being able to access
information via audition. Equipment must be worn and working. Teachers of the
deaf need to know how to manage this equipment, and be able to teach others
how to manage it: parents, classroom teachers, educational assistants for
example. This can be a challenge given the range of technologies they will encounter,
and the rapid pace at which the technology changes. Therefore a heightened empha-
sis on technology in teacher education is warranted, yet only 13 per cent of respon-
dents reported including instruction in troubleshooting cochlear implants as part of
their programme (Harrington & Powers, 2004). Ongoing professional development
to teachers of the deaf already in the field is also vital.
It is also the case that the majority of children with cochlear implants are educated
in inclusive settings in their local school. This means that, in contrast to having their
own class of deaf learners in a self-contained setting, most teachers of the deaf will be
working as part of a collaborative team to provide the appropriate programme in a
mainstream setting. A major aspect of this role is to be able to work and communi-
cate effectively with a range of individuals (e.g. classroom teachers, administrators,
speech language therapists, audiologists, and support workers such as teaching
assistants, interpreters, tutors, and notetakers). In addition, it often falls on the tea-
chers of the deaf to co-ordinate this team as they have the most direct contact with
the student; yet less than 50 per cent of teacher education programmes report any
focus on collaboration with general educators or other professionals as part of
the curriculum (Harrington & Powers, 2004).
Along with these changes in educational setting come shifts in expectations for
educational outcomes. As learners with cochlear implants evidence language out-
comes that are near age-appropriate, it has been anticipated that grade level per-
formance in reading, writing, and other academic areas will follow. While the
current evidence is not unequivocal, research does indicate a variable but overall
positive shift in literacy outcomes for learners with cochlear implants (Marschark
et al., 2010), and research reported here is likely to be conservative, being based
on children implanted later than currently the practice, with only one implant,
and with older technology. Teachers of the deaf will require a better understanding
of the reading and writing processes in typically hearing children and of the main-
stream curricula for literacy education. Rather than teaching a separate curriculum
or one designed for deaf learners, teachers of the deaf need to know how to appro-
priately differentiate the mainstream programme for learners with cochlear
implants. Familiarity and expertise in administering a range of assessment and
evaluation tools will also be key in monitoring progress in language and literacy,
and in ensuring that students are being educated in the most appropriate setting.
In addition to the even greater focus on the mainstream setting, teachers of the
deaf will be working with greater numbers of infants, toddlers, preschoolers, and
their families as implantation is routinely being done by 12 months of age in
many countries. They will also be working with more children with cochlear
implants who have additional disabilities as this group is being implanted in
increasing numbers. Most teachers of the deaf do not have expertise in providing
support to these groups of children, or their families, as the focus in teacher edu-
cation programmes has historically been on the impact of hearing loss, and not
other disabilities, on learning.
Clearly teachers and teacher educators face a myriad of challenges, and exciting
possibilities, as the population of learners with cochlear implants continues to
grow. Teacher educators will be challenged to review their existing programmes
and curricula in light of the changing context (e.g. Millett & Mayer, 2010), and it
will also be paramount to provide professional development for practising teachers
of the deaf.
The impact of cochlear implantation in children has not turned out as either the
critics or the supporters predicted. It is more complex than anyone could have
been anticipated. It has changed educational choices for parents and led to improved
levels of spoken language and educational attainments. However, cochlear implan-
tation has served to make an already diverse group, even more heterogeneous,
increasing demands on teachers of the deaf, and continuing to make educational
choices for their children a major issue for parents. If practitioners in deaf education
are to work with parents, students and researchers to identify the best possible long-
term support for this changing and diverse group of deaf learners, it may be possible
to utilize the opportunities afforded by cochlear implantation to enable the field to
move on from some of the old arguments and fulfil the predictions of Marschark and
Spoken language development of deaf children may be more possible today than
ever before. ..we are now presented with the opportunity to learn from earlier
mistakes and misunderstandings and to synthesize the best ideas of the past with
the technological, programming and social advances of today. …….we may
finally be able to fulfil the promise of effective support for speech and spoken
language with hearing loss. (Marschark & Spencer, 2006: 17)
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Notes on contributor
Correspondence to: Sue Archbold, The Ear Foundation, Nottingham, UK. Email:
... This may be partly due to children who are DHH being a challenging group for researchers. As a population, children who are DHH are a heterogeneous group with numerous variables to consider, including etiology and family history of hearing loss, type of loss (conductive, sensorineural, mixed), degree of loss (mild, moderate, severe, profound), age at identification, amplification history, cognitive potential, socioeconomic status, parental support, communication preference, and educational history (Archbold & Mayer, 2012;Marschark, 2018). The influence of cochlear implants in children as well as the variable and, therefore, unpredictable outcomes for each child (Punch & Hyde, 2010) has further added to the group's diversity and altered educational choices for caregivers, making the process of choosing an appropriate setting for their children a significant problem for some (Archbold & Mayer, 2012). ...
... As a population, children who are DHH are a heterogeneous group with numerous variables to consider, including etiology and family history of hearing loss, type of loss (conductive, sensorineural, mixed), degree of loss (mild, moderate, severe, profound), age at identification, amplification history, cognitive potential, socioeconomic status, parental support, communication preference, and educational history (Archbold & Mayer, 2012;Marschark, 2018). The influence of cochlear implants in children as well as the variable and, therefore, unpredictable outcomes for each child (Punch & Hyde, 2010) has further added to the group's diversity and altered educational choices for caregivers, making the process of choosing an appropriate setting for their children a significant problem for some (Archbold & Mayer, 2012). ...
... Because only three articles focused on the decision-making process were identified, a further search was conducted to include caregivers of children with other disabilities and the decision-making processes they experienced when choosing an educational setting for their child. This is particularly relevant for students who are DHH, as there are an increasing number of children who are DHH and who have additional disabilities (Archbold & Mayer, 2012;Marschark, 2018). ...
Decision-making is fundamental to everyday modern life (Porter, Creed, Hood, & Ching, 2018; Ranyard & Crozier, 2002). Some decisions require little thought, while others are more complex as options considered do not always lead to clear outcomes (Baron, 2008). Caregivers of children who are deaf or hard of hearing (DHH) are frequently confronted with complex decisions (Marschark, 2018), with the almost universal decision encountered being school enrollment choice. This systematic literature review explores worldwide research on factors effecting the decisionmaking processes of caregivers of children who are DHH when deciding on an educational setting. Three databases were searched and reference lists of identified articles examined, which resulted in a limited number of documents located. To broaden the scope of the review, another search was conducted to include caregivers of children with other disabilities. In all, nine articles were found and analyzed for common themes and sub-themes relevant to the decision-making processes of caregivers when choosing educational settings for their children who are DHH or who have other disabilities. Three broadly grouped themes were identified: child-centered, familial, and school. Five sub-themes were also identified: community inclusion, additional disabilities and wellbeing, complexity of decision-making, information input and flow, and school systems and personnel.
... When we conducted a systematic, international review of the literature on factors affecting the decision-making processes when caregivers of children who are DHH are deciding on an educational setting for their child, we found few studies (Stephens & Duncan, 2020). We broadened the scope of our review to include caregivers of children with other disabilities, as children who are DHH are increasingly diagnosed with additional special needs (Archbold & Mayer, 2012). Knowing what helped caregivers of children with other disabilities, we reasoned, may also benefit caregivers of children who are DHH, as their experiences in this area are likely to be similar. ...
Deciding on an educational setting for children who are deaf or hard of hearing (DHH) is a complex process that is not well understood. In the present study, the researchers' objective was to understand the factors caregivers consider when choosing a school for their child. Six caregivers of children who were DHH participated in semistructured interviews, which were coded into three themes (Child-Centered, Familial, School) and five subthemes (Inclusion, Additional Needs and Well-Being, Complex Process, Information Input and Flow, School Systems and Personnel). An unexpected theme (On Reflection) and three additional subthemes (Caregiver Perceptions of Education, School Character, No Regrets) were also identified. A highlighted finding is that when choosing an educational setting, caregivers of children who are DHH use decision-making processes that are complex and multifaceted. Practical implications for professionals supporting caregivers through decision-making processes are outlined, and applications for practice are suggested.
... The low performance of DHH children in PA may also be related to the problems caused by the hearing aids and cochlear implants they use in recognising and distinguishing sounds. Although hearing aids and cochlear implants provide access to sounds, this access is not the same as their typical hearing peers (Archbold & Mayer, 2012;Harkins & Bakke, 2011), which can make it more difficult for them to listen and recognise the sounds that make up a word, especially in noisy environments such as classrooms. This situation reflects negatively on their PA skills. ...
Children’s early literacy skills (ELS) are closely related to literacy learning and reading comprehension performance. Children who cannot acquire early literacy skills face significant difficulties in doing so in the following years. Although it is widely known that children who are deaf and hard of hearing (DHH) perform less well in early literacy skills than their typically developing peers, there is not enough information about the magnitude of the performance differences and in which skills these occur in Turkish-speaking children who are DHH. In this study, the early literacy skills (language, vocabulary, phonological awareness and letter knowledge) of 30 Turkish-speaking DHH children and 30 with typical development (TD) attending kindergarten were compared. The Coloured Progressive Matrices Test, as well as the Turkish early language development and Turkish expressive and receptive language tests, in addition to the early literacy one, were used to determine the children’s skill levels. The results of the analysis showed that the DHH children performed at significantly lower levels in language, vocabulary and phonological awareness skills than their peers with TD, while there was no major difference between the two groups in letter knowledge. The outcomes also revealed that there were a higher number of significant relationships among the early literacy skills of the DHH children than those with TD. The findings of are further discussed in regard to their contribution to current research and practice relating to the early literacy skills of Turkish-speaking children who are DHH.
... The development of language at an early age has increased the number of hearing-impaired children who enter mainstream schools [9]. However, their reading and grammar level varies, since their evolution depends on the age at which they received the implant and their rehabilitation process thereafter [10]. De Reave [11] argues that a successful insertion of these children in mainstream schools depends on auditory rehabilitation, which must be carried out by a multidisciplinary team that includes physicians, audiologists, teachers, speech and language therapists, psychologists, social workers and the family. ...
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Currently, a common objective for most countries is including people with disabilities in the various aspects of everyday life. As part of this objective, access to computer technologies that can help improve the learning of these people should be considered. In the case of hearing impairment, cochlear implants allow children with severe or profound hearing loss to develop natural language, which increases their chances of insertion in mainstream schools. However, the success of this depends on the auditory training process that involves various professionals and family members surrounding the implanted child. In this context, the use of mobile technologies has advantages due to their low cost and ubiquity; using mobile phones, children could learn new concepts as they train their hearing skills. Considering the above, in this paper, we present a review of mobile applications that hearing-impaired people can use for their learning and auditory training. The review is organized in two parts: (a) a systematic literature review, which included 297 articles on mobile technologies applied to hearing loss, and (b) a review of mobile applications aimed at teaching and training hearing-impaired children, which included 43 applications. The review was carried out taking into account technological, pedagogical and auditory aspects. The results obtained show the scarcity of learning applications that contribute to language development in hearing-impaired children. Additionally, some aspects that could be considered in the design of new mobile applications have also been identified, such as lack of visual interfaces based on augmented reality. This study opens up a new area where researchers and developers could work together in context-based mobile learning for hearing-impaired children.
... Even when children with CIs show strengths in spoken language, pragmatic difficulties may persist (Archbold & Mayer, 2012;Goberis et al., 2012). Pragmatics describes the use of language in context (Prutting & Kittchner, 1987), which means using language appropriately and effectively in interpersonal exchanges between two or more people (Zaidman-Zait & Most, 2018). ...
Many children who use cochlear implants (CI) have strong skills in many aspects of spoken language; however, limited information is available about their mastery of the pragmatic skills required to participate in conversation. This study reviewed published literature describing the pragmatic skills of children who use CIs in conversational contexts. Twenty-five studies met the inclusion criteria, and data were extracted describing participant characteristics, methodology, data type, outcomes, and factors associated with outcomes. Pragmatic skills were described in three broad categories: speech acts, turns, and breakdowns and repairs. Participants showed heterogeneity in age, age at implantation, duration of implant use, and languages used. Studies employed a variety of methodologies, used a range of different sample types and coding strategies, and considered different factors associated that might be associated with children's pragmatic skills. Across studies, children with CIs were reported to have a range of pragmatic skills in conversational contexts, from few to severe difficulties. The body of literature on this topic is small and considered heterogeneous children with CIs with a wide range of skills. Further research is needed to understand the pragmatics language skills of children with CIs and the factors influencing the diversity in skills observed.
... In Flanders, the Dutch speaking region of Belgium, 93% of newborn children with a profound and severe bilateral hearing loss are receiving cochlear implants (De Raeve, 2010). Evidence shows that children who receive a CI at a younger age perform better on a range of auditory (De Raeve, 2010), speech (Schauwers et al., 2005), and language measures than children implanted at an older age (Miyamoto et al., 2003;Anderson et al., 2004;Svirsky et al., 2004;Tomblin et al., 2007;Archbold and Mayer, 2012). Yoshinago-Itano (2006) suggested that earlyidentified profound hearing loss combined with early cochlear implantation and a high-quality auditory stimulation programme results in expectations that are similar to those of early-identified children with a mild-to-severe hearing loss, amplified by conventional hearing aids. ...
Introduction With the introduction of newborn hearing screening, children with different degrees of hearing loss can receive hearing aids and cochlear implants in the early months after birth, which is also the case in the Netherlands and in Flanders, the Dutch speaking part of Belgium. Materials and methods This has intensified the need for a validated questionnaire in the Dutch language to assess the speech development of children under the age of two. The LittlEARS Early Speech Production Questionnaire® (LEESPQ®), which was originally developed and validated in German language, was translated and validated into the Dutch language. Questionnaires of 355 normal hearing children were analysed. Results Total score was highly correlated with age (r = .775) and a normative curve was created. Internal consistency was reached with a high value of α = 0.870, which indicates that the questionnaire almost exclusively assesses speech production ability. The Dutch version of the LEESPQ®, is reliable, consistent and independent of gender or lingual status. As such, the Dutch LEESPQ®, may be a useful tool for language monitoring for children from birth to 18 months of age. Conclusion The Dutch LittlEARS Early Speech Production Questionnaire®, was found to be a reliable and valid tool to assess and monitor the early speech and language production skills in children up to 18 months of age.
... Even assuming that written forms of signed language were viable as a route to literacy, the cohort of deaf learners who would take advantage of this route would be limited to those who used ASL as a first language (L1). This group has never constituted the majority of the deaf school population and in the current context of universal newborn hearing screening and advances in hearing technologies including cochlear implants, bone-anchored hearing aids, and middle ear implants, its size is continually decreasing (Archbold & Mayer, 2012). Greater numbers of deaf children are now being educated in mainstream settings...and use a spoken language (albeit sometimes with sign or other visual support) as their primary means of communication. ...
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Understanding the importance of deaf students' opportunity to study literature in American Sign Language (ASL) is much needed, especially with the works originally developed in the signed language, not via translations of English literature. Additional considerations for the improvement in the education of deaf students include the need for methods for these students to develop reading skills in an effective manner that enables them to read and study English literature through their high school graduation. In this article, a brief pedagogical description of how deaf students best learn English literacy will lead to the discussion of signed language education as a model. A critical review of the traditional deaf/special education practices will confirm the reported lack of theoretical coherence for how deaf students are educated (e.g., Andrews, Leigh, & Weiner, 2004). Both ASL literature and English literature suffer the consequences of deaf/special education's emphasis on access to only information and activities. According to the Universal Design for Learning framework, deaf students need to enjoy access to learning. The signed language education model links to the concept of linguistic accessibility and provides a well-integrated setup for teaching both bodies of ASL literature and English literature to deaf students. These students would have the pedagogical means and skills to read English literature along with being masterful signers when given the opportunity to study ASL literature. The article will end with a review of promising ASL literature teaching research studies with deaf students that point to the face validity of the learning experience involved.
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READY is a self-report prospective longitudinal study of deaf and hard of hearing (DHH) young people aged 16 to 19 years on entry. Its overarching aim is to explore the risk and protective factors for successful transition to adulthood. This article introduces the cohort of 163 DHH young people, background characteristics and study design. Focusing on self-determination and subjective well-being only, those who completed the assessments in written English (n = 133) score significantly lower than general population comparators. Sociodemographic variables explain very little of the variance in well-being scores; higher levels of self-determination are a predictor of higher levels of well-being, outweighing the influence of any background characteristics. Although women and those who are LGBTQ+ have statistically significantly lower well-being scores, these aspects of their identity are not predictive risk factors. These results add to the case for self-determination interventions to support better well-being amongst DHH young people.
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Accéder à la connaissance scientifique est un droit humain et dans le contexte d’une école inclusive qui prend en compte la spécificité de chacun, rien n’empêche les jeunes sourds de comprendre les notions scientifiques enseignées. Or cela n’est pas aussi simple dans la réalité des institutions scolaires tunisiennes. Dans notre étude, nous nous intéressons à l’enseignement des sciences en général et à l’astronomie en particulier, dans le cas d’élèves sourds. Pour cela, nous avons exploré des conceptions en astronomie de 16 élèves sourds (16-19 ans), qui ont étudié des notions d’astronomie au lycée, avant et après une visite adaptée à la Cité des Sciences de Tunis. Nos résultats révèlent qu’après enseignement leurs connaissances en astronomies ne montrent pas de traces d’enseignement et leurs conceptions de l’Univers sont locales et pauvres en informations. Une visite adaptée à la Cité des Sciences a permis d’enrichir leurs connaissances et de faire évoluer les conceptions de certains d’entre eux.
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This chapter explores the large individual differences in speech and language outcomes in deaf children who have received cochlear implants (CIs). It argues that that the variability in performance on the traditional clinical outcome measures used to assess speech and language processing skills in deaf children with CIs reflects fundamental differences in the speed of information processing operations such as verbal rehearsal, scanning of items in short-term memory, and the rate of encoding phonological and lexical information in working memory. It is also shown that the sequela of deafness and delay in language are not domain-specific and restricted to only hearing and auditory processing. Other neurocognitive systems display disturbances, and these differences appear to reflect the operation of domain-general processes of cognitive control, self-regulation, and organization. © 2008 by Marc Marschark and Peter C. Hauser. All rights reserved.
The results of studies involving children in CHIP indicate that diagnosis of hearing loss within the first few months of life allows the opportunity to begin early intervention services for families with infants and that this early identification and early intervention results in significantly better language, speech, and social-emotional development. Earlier diagnosis allows the families to obtain information and receive counseling support over a longer period of time. Under these circumstances, intervention is commenced before the children are delayed in their language development. Families have the opportunity to provide their children with access to language that could prevent significant delay from occurring. Several outcomes have been observed in tracking the EIDRX children with significant hearing loss in Colorado. Most of these children have developed and maintained age-appropriate language skills, both orally and in sign language, and they exhibit a significantly higher level of competence in sign language when entering kindergarten. For the most part, the children with all degrees of hearing loss except profound (when using traditional amplification) have developed intelligible speech by entrance to kindergarten, regardless of their mode of communication and even when they have additional disabilities. In general, the research indicates that there are more children who are linguistically competent in two modalities, visual and auditory. The predictor variables for successful outcomes of EID children appear to differ from those of LID children. Future research should focus on the separation of these two groups to provide information about the unique intervention needs of each.
This chapter focuses on two developments that will speed up change in the population profile of DHH children: early identification through universal newborn hearing screening (UNHS) and early cochlear implantation. Studies show that children identified through UNHS within the first weeks of life have superior development on a wide range of measures, both linguistic and social-emotional, compared with children whose hearing loss was identified at later ages. The literature also provides compelling evidence of an improved rate and level of spoken language development for most children with severe to profound sensory-neural deafness who receive a cochlear implant, provided that they receive consistent input in spoken language. The chapter argues for an alternative approach to early intervention, which seeks to identify — at the earliest possible stage — those children for whom spoken communication may not be entirely accessible and for whom signed communication will likely be necessary to ensure their linguistic, social, cognitive, and emotional development. It then seeks to provide those children with a program focusing on the development of both spoken and signed language (or communication).
This chapter has two goals. First, it puts the idea of deaf cognition into a larger historical and theoretical context. Second, it considers specific foundations and outcomes of growing up deaf that reflect real differences between deaf and hearing individuals in today's world as well as differences among deaf individuals. These discussions can point the way toward a more comprehensive scientific understanding of human cognition and development, and better ways to optimize the educational and personal success of deaf learners of all ages. © 2008 by Marc Marschark and Peter C. Hauser. All rights reserved.
In the last two decades the population of deaf children has changed dramatically in these countries where universal hearing screening, early intervention, digital hearing aids, and cochlear implants are available. Most of these children can now acquire intelligible spoken language and they go to mainstream school in larger proportions. But mainstream placement does not eliminate the need for services, which will vary depending upon the child's age, school curriculum, language, and other child-specific factors. This paper reports on the content of all these changes and will also show you how one of the schools for the deaf in Belgium, called KIDS (Royal Institute for the deaf) has adapted his educational setting to their changing population of deaf children. The special school for the deaf became a service centre for the deaf. Within this service centre, which has to deal with the whole, very heterogeneous group of deaf children, there are several departments: early intervention, daycare centre, pre-, primary and vocational training school, mainstreamed support service, audiological centre, and residential department. All this is a big challenge for the management of the service centre, who must ensure that their staff have the skills to meet these challenges.
The educational settings of 42 implanted profoundly deaf children 3 years after implantation were compared with the respective settings of 635 age-matched severely deaf and 511 profoundly deaf children with hearing aids. All implanted children received their implants before beginning school. The results revealed that 3 years after implantation, 38% (16 children) of the implanted profoundly deaf children attended mainstream schools, whereas 57% (24 children) were in a unit, or special class, in a mainstream school, and 5% (two children) were in schools for the deaf. With regard to the age-matched profoundly deaf children with hearing aids, 12% (63 children) attended mainstream schools, whereas 55% (281 children) were in a unit of a mainstream school, and 33% (167 children) were in schools for the deaf. In the group of age-matched severely deaf children, 38% (239 children) attended mainstream schools, whereas 51% (326 children) were in a unit of a mainstream school, and 11% (70 children) were in schools for the deaf. Statistical analysis revealed a highly significant difference between the educational placement of implanted children and hearing-aided profoundly deaf children (p < 0.00001), whereas there was no statistically significant difference between implanted children and hearing-aided severely deaf children. In conclusion, implanted profoundly deaf children who have received their implants before beginning school have the same profile of educational placement as aided severely deaf children rather than aided profoundly deaf children of the same age in the UK. This is likely to have significant implications for the future management of profoundly deaf children and to influence future planning of educational support services.
It is the responsibility of teacher educators to provide current information in response to changes in technology. The success and availability of cochlear implants in recent years has created a need for teachers of students who are deaf to obtain the knowledge and skills in preparation programs to successfully work with children who have these assistive devices. The directors/chairs or coordinators of the 70 teacher preparation programs for teachers who serve children who are deaf or hard of hearing in the United States were surveyed to discover what information is provided to preservice teachers about cochlear implants and the subsequent implications for intervention. Information pertaining to demographics, knowledge, skills and materials was obtained. The respondents to the survey provided information indicating that teacher preparation programs for teachers of children who are deaf and hard of hearing are at various stages of development with regard to including knowledge and skills appropriate for working with children who have cochlear implants or for collaborating with general education teachers and other professionals who are involved in working with children who have implants. Suggestions for future research are presented in addition to modifications and enhancements to existing teacher preparation programs for teachers of children who are deaf or hard of hearing.
Deaf learners whose first language is American Sign Language face particular challenges and constraints in developing literacy in English as a second language. These constraints are interrogated and discussed in terms of their relationship to issues of language proficiency in both L1 and L2, and to models of second language literacy education. Suggestions are proposed as to ways in which these constraints might be addressed in designing future bilingual programs for deaf learners.
Two surveys of parents of children with cochlear implants were conducted to assess trends in children's educational needs. The majority of children used spoken language and attended mainstream though there was diversity both in terms of the children's language modality and school placement. In both years of the survey, approximately one-third of families noted they had difficulty obtaining the special education services their child needed at school.