Royal College of Speech & Language Therapists Clinical Guidelines: 5.7 Deafness/Hearing Loss
Taylor-Goh, S. (ed). (2005).
Bicester (United Kingdom): Speechmark Publishing Ltd., 53-61.
This evidence-based guideline provides recommendations for the assessment and management of communication disorders caused by deafness or hearing loss in children and adults. This guideline is intended for speech-language pathologists.
Royal College of Speech & Language Therapists (United Kingdom)
<div>When appropriate, the assessment should include an evaluation of preverbal communication skills including symbolic play, eye contact, turn-taking and independence in spontaneous interaction and communicative contexts (Grade B Evidence).</div>
<div>Auditory training is an essential prerequisite to any speech production work for children for whom spoken language will be the primary mode of communication. Auditory training extends from closed-set activities to functional listening which may include auditory/speech-reading activities (Grade B Evidence). "Auditory training will form an essential part of the management of speech intelligibility for those deaf children for whom spoken language will be the primary mode of communication. This extends from closed-set activities to functional listening. Functional listening may include auditory/speech-reading activities. It is, therefore, a prerequisite to any speech production work" (Grade B Evidence; p. 59).</div>
<p>When appropriate to the child, management of hearing loss in children should include the following:</p>
<ul>
<li>intervention to develop early communication skills (e.g., eye contact, initiation, turn-taking);</li>
<li>approaches to develop social and interaction skills (e.g., non-verbal communication, discourse skills, social communication skills, compensatory strategies for communicative deficits);</li>
<li>direct or indirect strategies to facilitate the development of receptive and expressive language skills;</li>
<li>environmental modifications to make language and communication more accessible;</li>
<li>auditory training;</li>
<li>direct treatment to improve the child's speech or sign intelligibility; and</li>
<li>speech reading (Grade C Evidence).</li>
</ul>
<div>"Post-lingually deafened adults and some, but not all, school-aged deaf children may require assessment with closed-set speech perception materials" (Grade C Evidence; p. 56).</div>
<div>The clinician should evaluate speechreading abilities at the single word and connected discourse levels with consideration for visual and auditory-visual strategies (Grade C Evidence).</div>
<div>"The individual's ability to use their aided hearing for functional listening in everyday home, school or work environments should be assessed" (p. 54) in addition to their aided ability to detect, discriminate, and identify environmental and linguistic sounds (Grade C Evidence).</div>
<div>"Direct therapy may be needed to improve the ... speech ... intelligibility [of a child who is deaf or has a hearing loss].... Speech intelligibility therapy might take place at the phonological and/or phonetic level and may include both segmental and supra-segmental features. Therapy at this level should be preceded by the development of speech perception skills" (Grade B Evidence; p. 59).</div>
<div>The clinician should assess the individual's functional voice, including quality, pitch, range, resonance, and volume in several communicative contexts (Grade C Evidence).</div>
<div>Speech-reading may be a prerequisite for auditory training and "may facilitate recognition of lip shapes, anticipation and use of context from very basic lip patterns to single words to running speech" (Grade C Evidence; p. 59).</div>
<div>"A formal assessment and/or skilled observation of the ... phonetic and phonological repertoire [of a child who is deaf or has a hearing loss] may be appropriate, and a profile of their speech ... intelligibility in a range of communicative contexts should be drawn up. This should include both their use of segmental and supra-segmental features in spoken language" (pp. 56-57).</div>
<div>The clinician should also assess social and interaction skills across a range of contexts, including gesture, facial expression, social communicative behavior, and discourse skills in both spoken and sign languages. Compensatory communicative strategies should be observed and noted.</div>
<p>When appropriate the assessment should include an evaluation of:</p>
<ul>
<li>social and interaction skills including gesture use and understanding, facial expressions, social communication skills, and discourse skills (Grade C Evidence);</li>
<li>understanding and use of language in all relevant modalities including an analysis of use and understanding of semantics and grammar (Grade C Evidence);</li>
<li>aided and unaided auditory skills (Grade C Evidence);</li>
<li>speech production and intelligibility (Grade C Evidence); and</li>
<li>vocal characteristics including prosody, pitch, resonance, and range (Grade C Evidence).</li>
</ul>
<div>When appropriate, clinicians may provide advice on classroom management to facilitate access to the curriculum. This may involve:</div>
<ul>
<li>modification of methods of presentation of information;</li>
<li>development of a range of tools to aid organization;</li>
<li>different methods of delivery; and/or</li>
<li>staff training (Grade B Evidence).</li>
</ul>
<div>The clinician should formally evaluate the individual's phonetic and phonological repertoire in a range of communicative contexts as appropriate. A profile of speech and/or sign intelligibility should be created considering both segmental and non-segmental language features (Grade C Evidence).</div>
<div>The clinician should assess the individual's multimodal receptive and expressive communication including gesture, spoken language, speech, sign language, and written language. The assessment of sign language competence will require close collaboration with fluent sign language users (Grade C Evidence).</div>
<div>Clinicians should collaborate with others to adapt the physical, social, sensory, and linguistic environment to enhance language and communication accessibility (Grade C Evidence).</div>
<div>An assessment should include the child's ability to use their amplification for functional listening in everyday situations. It should also include the child's use of multi-modal communication (e.g., gesture, sign). Assessment of sign language competence will require collaboration with fluent sign users. The speech-language pathologist will need to consider the unique needs of children with hearing loss from multi-lingual backgrounds (Grade C Evidence).</div>
<div>Consider direct therapy to improve sign intelligibility in conjunction with a trained and competent sign language user (Grade B Evidence).</div>
<div>"The [speech-language pathologist] SLP will explain the relationship between hearing and communication, and will be available for discussion and support. Intervention should seek to facilitate the development of early communication skills, particularly appropriate eye contact, initiation, communicative intent, and turn-taking skills" (Grade C Evidence; p. 58).</div>
<div>Direct and/or indirect approaches may be appropriate to:</div>
<ul>
<li>develop non-verbal communication;</li>
<li>develop conversational and discourse skills;</li>
<li>develop the social rules of communication;</li>
<li>teach strategies used to compensate for linguistic or communicative difficulties; and</li>
<li>improve receptive and expressive aspects of spoken, signed, or written language (as appropriate) including semantic, grammatical, and phonological competencies (Grade C Evidence).</li>
</ul>
<p>In addition to gathering information about medical history, the clinician should consider collecting the following case history information:</p>
<ul>
<li>age at diagnosis, type, nature, and etiology of hearing loss;</li>
<li>age at intervention;</li>
<li>audiological test results;</li>
<li>type of amplification, age at fitting, and consistency of use (if applicable);</li>
<li>recommended hearing aid settings and use of environmental devices (if applicable);</li>
<li>first language, including sign language;</li>
<li>preferred language(s) and communication system(s), including sign language, manually coded English, cued speech, gesture, and speech;</li>
<li>level of speech reading competency;</li>
<li>other audiological/vestibular symptoms (e.g., tinnitus, balance impairment);</li>
<li>need for an interpreter; and</li>
<li>links to Deaf community (Grade C Evidence).</li>
</ul>
