Audiologic (Re)Habilitation Curricula & Programs Melissa Hall, AuDAudiologic Rehabilitation for Children and Educational AudiologySPA 6581 – Spring 2015Lecture Date: 02/17/2015

Current Issues in Deaf Education

Accountability and Oversight

Communication & Communication Access

Low Expectations &S Inadequate Instruction

Lack of Evidenced-Based Practices

Students with Hearing Loss Who Do Not Have Individualized Education Programs

Recruitment &S Retention

Parent Involvement Early Hearing Detection

& SIntervention and Early Childhood Education

Technology Funding and Resources Deaf vs. Hard of Hearing

Best Practicesin Educating children who are deaf and hard of hearing

Best Practices Program

Standards Program Review Evidenced-Based

Practices Consensus-Based

Practices

Educational Assessment

Progress Monitoring

Expanded Core Curricula

Observation Checklists

Program Standards

Standards that are promoted should contain evidence of benefit and research that justify their practice.

It should be determined which standards are most critical to improving student and family outcomes.

Program Review Periodic review of programs and services

Necessary to identify gaps and to monitor implementation of new components of the program

Provides an opportunity to educate others regarding basic program parameters and the need for refinement or more significant changes

Colorado Quality Standards for Programs and Services for Students Who Are Deaf and Hard of HearingSections 1 through 5

Section 1 – Identification and Referral

Identification and Referral

Collaboration

Hearing Screening

Audiological Referral

Vision Screening

Section 2 – Assessment of Unique Needs

Persons Conducting the Assessment

Domains to be Assessed

Test Administration

Specialized Services, Materials and Equipment

Assessment Team

Placement Considerations

Section 3 – Support for Instruction and Learning Statement of Purpose Policy on Language

and Communication State Oversight Regional/Cooperative

Programs Continuum of Options Students with Multiple

Disabilities Program Administrator

Staff Qualifications Other Qualified

Personnel Workload Management Staff Development Training for General

Education Personnel Facilities Program Accountability Self-Assessment

Section 4 – Learning and Instruction

Cohesive Team

Focus on Communication

Focus on Authentic Peer Interactions

District Core Curriculum and Standards

Supplemental Specialized Curricula

Transitions

Purpose of Assessment

Section 5 – Parent, Family, and Community Involvement

Parent Training and Support

Parent Leadership and Participation in Program Development

Deaf/Hard-of-Hearing Adults & Community Involvement

Evidenced-Based PracticesRefers to an approach in which current, high-quality research evidence is integrated with practitioner expertise and client preferences and values into the process of making clinical decisions.

In making clinical practice evidence-based, audiologists and speech-language pathologists need to… recognize the needs, abilities, values, preferences, and

interests of individuals and families to whom they provide clinical services, and integrate those factors along with best current research evidence and their clinical expertise in making clinical decisions;

acquire and maintain the knowledge and skills that are necessary to provide high quality professional services, including knowledge and skills related to evidence-based practice;

evaluate prevention, screening, and diagnostic procedures, protocols, and measures to identify maximally informative and cost-effective diagnostic and screening tools, using recognized appraisal criteria described in the evidence-based practice literature;

In making clinical practice evidence-based, audiologists and speech-language pathologists need to… evaluate the efficacy, effectiveness, and efficiency of

clinical protocols for prevention, treatment, and enhancement using criteria recognized in the evidence-based practice literature;

evaluate the quality of evidence appearing in any source or format, including journal articles, textbooks, continuing education offerings, newsletters, advertising, and Web-based products, prior to incorporating such evidence into clinical decision making; and

monitor and incorporate new and high quality research evidence having implications for clinical practice.

Consensus-Based Practices Given the lack of evidenced-based practices, many

teachers and clinicians focus on consensus-based practices

Ones that we agree are good practices to implement with DHH students even though we lack sufficient scientific evidence to support their use

Potential difficulties with consensus-based practices? Funding Outcomes Prognosis Others?

Educational Assessment Reasons for Assessment

Identify student needs Plan instruction Evaluate student

progress Evaluate instructional

programs Document student’s

achievement Evaluate professionals Evaluate schools and

school districts

Categorization of Assessment Purpose Diagnostic for

special education eligibility and program planning

Curriculum-based for progress monitoring

Method of Assessment

Progress Monitoring Process of collecting ongoing data to monitor skills that are

important for students to be successful in school Data are then used to adjust instruction to increase performance Performance benchmarks

Need to be conducted frequently to monitor progress in core academic subjects

Measures may occur: Weekly Biweekly Monthly As needed

Curriculum-based measurements (CBMs) A method teachers use to find out how students are progressing in

basic academic areas such as math, reading, writing, and spelling.

Expanded Core Curricula These topics expand on the required school

curricula to address specific instruction in areas that are unique to deafness and hearing loss

Challenge 1 Adding these curricular areas

Challenge 2 Who will teach them Where will the instruction be fit into the school

day

Expanded Core CurriculaFor Students Who Are Deaf and Hard of Hearing

Communication and Language Development All children have the right

to an effective & efficient communication system as a precursor to language development

Family Education Effective communication &

language development cannot occur without the support & involvement of the family.

Audiology Students are

empowered when they understand their hearing loss.

Technology Technology improves

quality of life, provides access, and is vital for emergency information.

Expanded Core CurriculaFor Students Who Are Deaf and Hard of Hearing Transition

DHH students and their families need specialized information about life skills, vocational rehabilitation, social security, and laws.

Social Interaction Skills Incidental learning

through audition is hindered when there is a hearing loss, whether it is mild or profound.

Deaf Studies Students may benefit from

studying the history, language, and contributions of the Deaf community.

Advocacy Students and their families

need knowledge in areas such as requesting reasonable and appropriate communication access, requesting interpreters, advocating for legal rights, accessing services after high school, ADA, Section 504, and IDEA

Teaching Spoken LanguageNormal, everyday interactions

Incidental Interacting

Adults are teaching children every time they interact with them, whether or not they are aware of it

“Worm on the sidewalk” example

Embellished Interacting

Expand upon the incidental interaction

Think of this as… Incidental seizing-of-the-

teachable-moment is embellished interacting, or embellished teaching by the adult.

Incidental Teaching Child is 2 ½ years old with hearing loss Parent and child take a walk. They come upon a live worm on the sidewalk.

The child points and says, “Look! Worm!” Child continues to look at the worm

The parents bends down and replies, “Yes – I see it. Look! The worm is wiggling!”

Parent is teaching child: What child says is meaningful and of communicative value to the parent That people respond to each other in conversations The response is generally related to the semantic content of the previous

speaker’s utterance Teaching present progressive form (be + verbing) Auditory event – parent is within 18 inches of the child’s hearing aids, child is

looking at the worm not the parent’s face

Embellished TeachingPart 1 - Incidental The child points and says, “Look! Worm!”

Child continues to look at the worm The parent bends down and replies, “Yes – I see it. Look! The worm is

wiggling!”Part 2 - Embellished Parent - “Wiggle, wiggle, wiggle. The worm is still wiggling!” (Pause for child

to respond) Parent – “Oh look! There’s another worm that’s wiggling.” (Pause while the

child finds another worm) Parent – “Oh – you found another one! Is that worm wiggling?” (Pause.) Parent – “Yes, it is! Oh, that’s funny. Can you wiggle like a worm?” (And so on)

In the parent’s mind… Wiggle has become a vocabulary goal Parent is providing varied, repetitive exposure to that goal and attempting to elicit

it

Learning Contexts & Teaching Approaches

Incidental Learning

Embellished Informal Teaching

Semi-Formal Teaching

Formal Teaching

Happens in normal, everyday events and interactions

Seize the moment

Adult directed, pre-planned activities

Adult directed

Should occur at home and school

Use of strategies to embellish the normal situation

Developmentally appropriate

Deliberate, direct, methodical

Should occur at home and school

Specific goals and objectives

Specific goals and objectives

Use of strategies Use of strategies

Typically done at school

Happens in traditional educational setting

All learner types All learner types Delayed & remedial learners

School age remedial learners

Types of LearnersDevelopmental Delayed Remedial

English Language Skills

Within 1 year of typically developing peers

1-2 yrs behind peers

Greater than 2 yrs behind peers, scattered language skills

Learning/Teaching Context

Informal Learning Primarily semi-formal, also need informal

Formal learning, with generalized to informal

Educational Placement

Fully mainstreamed by preschool/kindergarten

Mainstreaming by kindergarten may be a challenge due to language gap

One hour/per day/per year; social mainstreaming

Observation Checklists The Preschool/Kindergarten Placement Checklist from

the Placement and Readiness Checklist (PARC) Assists parents and early intervention providers in

conducting systematic observations of classrooms to select the most appropriate placement for each child

Checklist functions to set up expectations

Student Checklists Should be used by the IEP team to identify a supportive

and accessible classroom Also help to identify training needs that can be

addressed before placement

Effective Practices in Closing Achievement Gaps (Schwartz, 2001) State and District Roles

Development and implementation of accountability standards Dissemination of existing research-based instructional programs Dissemination of information about effective instructional strategies

Early Childhood Provision of high-quality preschool programs Provision of family literacy programs

School Climate Identification and identification of every student’s potential Maintenance of a safe and orderly school

School Organization Smaller classes in earlier grades Equitable grouping of students

Teaching and Learning Provision of increased instructional time in reading, mathematics, and other basic

skills Provision of supplemental individualized education supports Provision of learning resources

Intervention Issues

The most effective ingredients of intervention for young children who have hearing loss include: Beginning intervention when the child is very

young Following a normal developmental sequence Having parents be the primary teachers of their

children

Educational Programs Differ on several important dimensions

Intervention: 4 Basic Premises 1st Premise

Begin intervention with children who have hearing loss when they are very young Research/evidence based

Sensitivity of the brain’s neural pathways Verbal and academic deficits seen when intervention begins

later

2nd Premise Help the children learn to listen and talk

Keep as much of the world open to them as possible 3rd Premise

Help the parent help the child learn spoken language through listening

4th Premise Acquiring spoken language through listening, a child

with a hearing loss will generally follow a normal developmental path

Differentiating Dimensions of AR Programs Public and Private Close inspection of the programs reveal that they vary on

several theoretical and methodological dimensions

Distinctions: 1) The nature and manner of parent involvement in the child’s

learning can be different in different programs. 2) Programs vary in the emphasis placed on normal everyday

interactive events as the context within which the child will learn language, versus an emphasis on the child learning language from participating in adult-directed teaching activities.

3) Programs and interventionists also vary in their use of sense modalities in providing spoken language input, both in normal everyday conversations and in more adult-directed activities.

Distinction 1 – Parent Involvement # of sessions per week

Whether or not parent is in the therapy room or observing from outside

Who is the person who interacts primarily with the child? Parent or therapist?

Location of the session

Parent group meetings and activities outside of the sessions

Nature and amount of information supplied to the parent about how to help the child outside of the intervention sessions

Distinction 2 – Language Learning Environments

Programs differ on the extent to which they employ either model

Developmental model

Remedial model

Distinction 3 – Use of Sense Modalities Three likely avenues of sensory input for

spoken language

Audition

Visual

Tactile

Curricula/Training Programs

Program Selection Audition – Audiologic Re(Habilitation)

Literacy

Look for a program in which: Children can maximize their auditory

potential all day where they are expected to learn to listen and speak

Spoken language is the primary language The curriculum prepares children for

mainstreaming

Program Selection… Ensure the program offers:

Individualized Family Service Plan (IFSP) for children birth to 3 yrs or Individualized Education Program (IEP) for children 3 yrs+

Quality and professional education of the staff, including playtime supervisors, counselors, and others

Curricula that prepare the child for transitions A social and physical environment that supports

the child’s efforts to learn to listen and speak Comprehensive audiological management

Requirements of AR Program Qualified Professionals from the AR Team

Individual sessions

Parents and clinician are partners

Focus on listening/audition

Case manager – clinician or audiologist

Requirements of AR Program

Session begins with a discussion about progress and any problems encountered during the previous week

Session continues according to the lesson plan Goals: audition, speech, language, communication, cognition

Developed concurrently

Session ends with the therapist discussing strategies for generalization and integrating the goals from the lesson into everyday activities at home and in the community

Typical Habilitation Session

Requirements of AR ProgramClassroom and Therapy Rooms

Dedicated, quiet and non-reverberating room

Child friendly environment

Video camera Storage for toys (out of

sight) *May not be possible…

Teaching Resources Resources:

Toys, games, puzzles, and books Basic concepts: quantity, shapes,

colors, time, size, weight, temperature

Lesson Plan: Audition, speech, language,

cognition, and communication goals

Parents need a notebook to record activities and goals

Video the sessions Good evaluation tools to see and

measure progress

Requirements of AR ProgramGoal Setting: Long-Term

Age appropriate speech and language

Effective auditory comprehension

Intelligible speech Communicative competence Mainstream education Graduate from an AR program

into a regular school when they are age appropriate in their speech, language, and communication

Goal Setting: Short-Term

Follow developmental sequence based on needs of the individual child: Audition

Use the 5 Levels of the Auditory Learning Guide (ALG) Sound Awareness Phoneme Level Discourse Level Sentence Level Word Level

Speech, Language, Cognition, and Communication goals

Requirements of AR Program Planning the Weekly Lesson

Use developmental model to set your goals, and remedial as appropriate

Based on goals in the 3-6 month plan Complete record of activities Will become the diagnostic raw material for when the

child’s progress will be reviewed Include Ling 6-7 Sound Check Learning to Listen Sounds

Sounds that are associated with toys commonly used by babies and very young children

Many of these sounds contain acoustic properties that are significant in perception of speech

Curricula/Training Programs The Auditory Learning Guide SkI-HI Model Curriculum Speech Perception Instructional Curriculum Evaluation (SPICE) Auditory Skills Program

for Students with Hearing Impairment St. Gabriel’s Curriculum for the development of Audition, Language,

Speech, and Cognition CHATS: The Miami Cochlear Implant, Auditory and Tactile Skills

Curriculum Listen, Learn, and Talk Spoken Communication for Students Who are Deaf or Hard of Hearing:

A Multidisciplinary Approach AuSPlan (Auditory Speech Language): A Manual For Professionals

Working With Children Who Have Cochlear Implants Or Amplification (2003)

Structured Methods in Language Education (SMILE) Contrasts for Auditory and Speech Training (CAST)

Curricula/Training Programs Building Skills for Success in the Fast-Paced Classroom: Optimizing

Achievement for Students with Hearing Loss  Cottage Acquisition Scales for Listening, Language, and

Speech (CASLLS) Bringing Sound to Life: Principles and Practices of Cochlear Implant

Rehabilitation My Baby and Me Phono-Graphix See-the-Sound Visual Phonics Top Ten Strategies for Parents Learn To Talk Around The Clock Classroom Goals: Guide For Optimizing Auditory Listening Skills Colorado Model: Partnering with Families – A Clinical Training Manual Parent-Infant Communication (4th Edition) Teaching Activities for Children Who Are Deaf or Hard of Hearing – A

Practical Guide for Teachers

THE SKI-HI MODEL CURRICULUM (2004)

Sensory Kids Impaired Home Intervention Offers support and resources in natural environments Infants, toddlers, and preschoolers (birth to 5 years) who are DHH Comprehensive family oriented curriculum Information and activities for families:

Early communication Audition Hearing aids American Sign Language (ASL) resources Aural-oral language Total communication Psycho-emotional support

Five follow-up language programs are offered: Bi-Bi, Signing English, Aural-Oral, Cued Speech, and ASL Emphasis*Must be trained prior to using the program*

Speech Perception Instructional Curriculum Evaluation (SPICE) Curriculum kit for developing speech/listening

skills/processing skills in children who use either CIs or HAs Program provides a sequence of lesson objectives, as well as

activity suggestions for each objective Ages 3 to 12 Can be adapted to a variety of language levels Goals for the curriculum:

Detection Supra-segmental perception Vowels and consonants Connected speech

Available through: Central Institute for the Deaf

Auditory Skills Programfor Students with Hearing Impairment New South Wales (NSW) Department of Education and Training Curriculum for students in Kindergarten to 6th grade Systematic program designed for teachers to develop speech and language

through listening in their students with hearing impairment Guides the development of students’ language skills in quiet and noise

conditions: Detect sounds Comprehend and use spoken language at:

Discourse level Sentence level Word level

Phonemes and suprasegmentals Allows for developmental and remedial teaching

Placement tests designed to pinpoint appropriate starting places in the program A section on audiological management provides comprehensive information to

guide teachers and support personnel in establishing daily routines to maintain listening devices at optimum levels.

St. Gabriel’s Curriculum for the development of Audition, Language, Speech, and Cognition Available through: Alexander Graham Bell Association Guide for professionals working with children with hearing loss from birth

to 6 yrs Developmental sequence for the areas

Audition Component Auditory awareness, 7-sound test, auditory memory

Language Component Expressive and receptive developmental sequence for the structures of English

Speech Component Developmental stages of early speech, development of auditory feedback skills,

order for acquisition (vowels, diphthongs, and consonants), checklist of phonological processes

Cognitive Component Hierarchical order for the development of critical thinking skills

Initially developed for a center utilizing the Auditory-Verbal approach Can be adapted to students using a range of communication

methodologies and educational approaches

CHATS: The Miami Cochlear Implant, Auditory and Tactile Skills Curriculum Available through: Alexander Graham Bell

Association Sequence of goals to facilitate auditory

development for students of all ages using a variety of technologies including cochlear implants

Receptive and expressive goal categories Objectives within each category follow a

developmental sequence Activities are provided to support the goals in

each category

Listen, Learn, and Talk Available through: Cochlear Corporation Auditory habilitation program for young DHH children

who are learning to listen and talk Program consists of:

Manual Importance of parent participation Theory behind auditory development Strategies for facilitating spoken language development Integrated scales for monitoring/documenting development

in listening, language, speech, cognition, and social communication

Three Videotapes (Babies Babble, Toddlers Talk, and Children Chatter)

Spoken Communication for Students Who are Deaf or Hard of Hearing: A Multidisciplinary Approach

Speech text Supports using a multidisciplinary team approach

to develop spoken communication skills regardless of the type and degree of hearing loss or the educational philosophy

Multidisciplinary team: Teachers, speech therapists, parents, school

personnel, and students Classroom setting

Provides pictures, forms, discussions, experiments, and practical ideas for use in school or home

AuSPlan (Auditory Speech Language): A Manual For Professionals Working With Children Who Have Cochlear Implants Or Amplification (2003)

Available through: Advanced Bionics Developed by: Adeline McClatchie and Mary Kay

Therres Guide for professionals in developing a communication

therapy plan for children with cochlear implants and/or hearing aids

Framework for rating child’s potential to use a cochlear implant and performance outcomes 3 components:

Pre-Implant Candidacy and Prediction of Realistic Outcomes Expected Educational Placement and Support Services Specific auditory, speech, and language goals

Structured Methods in Language Education (SMILE) Available through: Alexander Graham Bell Association Multisensory program that teaches

Speech Reading Writing

Children with severe language and communication delays Hearing loss Dyslexia Autism spectrum

Engaging yet simple Expressive and receptive language to improve reading

skills

Contrasts for Auditory and Speech Training (CAST) Available through: Linguisystems Ages 3 to 12, Grades Pre-K to 7 Analytic auditory training program Designed for children with:

Hearing loss, cochlear implants, and hearing aids Weakness in auditory discrimination Disorders of speech sound awareness

Helps them learn to recognize speech sounds and identify words as they contrast pairs of stimuli Starts with grossly different acoustic characteristics then progresses to

finer acoustic distinctions Includes:

Pre-test Step-by-step procedures for analytic auditory training Progress log

Building Skills for Success in the Fast-Paced Classroom: Optimizing Achievement for Students with Hearing Loss 

Available through: Butte Publications Authors: Karen Anderson and Kathleen Arnoldi Book which provides resources that will assist students in optimizing

their achievement through improved access and self-advocacy Targets the “expanded core curriculum”

Skills that must be mastered in order to benefit from the core curriculum Key features of the book

Approaches to eligibility for students who appear appropriate in language and academics but are at risk for developing academic gaps and potential social communication issues

Communication repair Social/emotional issues Self-advocacy

Applicable to students with hearing loss of all degrees Particularly useful for students who are mainstreamed

Cottage Acquisition Scales for Listening, Language, and Speech (CASLLS) Available through: Alexander Graham Bell Association A product to help assess, select objectives, and plan instruction to

document and facilitation language acquisition in children with hearing loss

Based on language development beliefs of researcher: Christie Yoshinaga-Itano (Language assessment of infants and toddlers with significant hearing

loss, Seminars in Hearing, 1994) Set of scales

Pre-verbal Pre-sentence Simple sentence Complex sentence Sounds and speech

Follows a developmental approach of language, listening, cognition, and speech

Bringing Sound to Life: Principles and Practices of Cochlear Implant Rehabilitation

Available through: Advanced Bionics Systematic approach to spoken language habilitation for

children of all ages Helpful for providing insights, strategies and tools Resource for family education and/or teacher training

Includes: Video training series

Building Blocks of Spoken Language Understanding Hearing and Hearing Loss Cochlear Implants and Children: An Opportunity, Not a Cure Principles and Practices of Cochlear Implant Rehabilitation

Manual Program to develop phoneme perception WASP – Word Associations for Syllable Perception

My Baby and Me Developed by: Betsy Moog Brooks of The Moog Center for Deaf

Education Notebook-style resource for parents (and the professionals that

work with the families) Provides strategies and tips for helping a child learn to listen and

talk Personalized for each child and family Information

Language learning Hearing loss

Developed for families using an “oral only” approach to communicating with their hearing impaired child Information is beneficial for any family interested in developing and

documenting their child’s spoken language skills regardless of the communication methodology chosen

Phono-Graphix Available through: Read America Supports phonemic development and reading Includes:

Instructional manual and materials This program can be used as part of a reading

and/or speech development program

More of a supplemental tool than an AR program

See-the-Sound Visual Phonics Available through: International Communication Learning

Institute Combines the following cues to assist in developing phonemic

awareness, speech production, and reading skills: Visual Tactile Kinesthetic Auditory feedback

Provides a system to help children with hearing loss “see” and internalize English phonemes

45 hand movements for phonemes that relate to how a sound is produced

Must participate in a formal training session prior to using this program

Top Ten Strategies for Parents Available through: Alexander Graham Bell Association

Developed by Jill Bader, Founding Director of the Hear at Home program in Colorado For children with hearing loss

Materials: Manuals include clearly written descriptions of ten

strategies to facilitate a child learning to listen and speak 1 manual for families 1 manual for professionals working with families

Videos

Learn To Talk Around The Clock Available through: Alexander Graham Bell Association Oral, early intervention program Designed for professionals who work with families of

children who are deaf or hard of hearing Focuses on language learning in the child’s home

environment Provides a toolbox for professionals to maximize the

caregiver’s language development techniques by encouraging interactions during everyday activities

Premise Providing opportunities for interaction in everyday life provides

the groundwork for auditory and language development Curriculum includes: toolbox and video

Classroom Goals: Guide For Optimizing Auditory Listening Skills Available through: Alexander Graham Bell Association Designed to support development of auditory learning

regardless of: Hearing level Type of amplification used Grade level Mode of communication

Describes practical ways for teachers to create situations to encourage development and use of residual hearing in the classroom

The actual activities are content specific, but the strategies they employ can be applied to any content area or book.

Colorado Model: Partnering with Families – A Clinical Training Manual Early Intervention

Designed specifically to serve families of children with hearing loss, from birth to preschool, in the secure surroundings of their own homes Parent facilitator

Designs an individual program that fits both the family’s needs and the child’s learning style

Helps family members to develop techniques to encourage their child’s speech, language, and listening skills

Colorado Home Intervention Program (CHIP) Provides services to families of deaf and hard of hearing children Focus on family-centere

Parent-Infant Communication (4th Edition) Available through: Butte Publications Developed by: Valerie Schuyler and Jane Sowers

Family-centered curriculum of listening and communication skills development for children Birth to 4 yrs

Follows developmental sequence for auditory and language skills acquisition

Guide parents in promoting their child’s listening and language development

Teaching Activities for Children Who Are Deaf or Hard of Hearing – A Practical Guide for Teachers

Developed by: Jean Sachar Moog, Karen Kusmer Stein, Julia J. Biedenstein, and Christine H. Gustus

Book which provides overall guidelines to help teachers decide what to teach, and how and when to teach it.

Intended for use by teachers to focus on the following: Vocabulary Syntax Conversational activities Language expansion

Remember…Not every child with severe to profound hearing loss does learn to talk, sometimes in spite of the best efforts of parents and professionals. Let’s do what we can! Reasons for lack of satisfactory progress in spoken language can

include: Late diagnosis Poorly fitting and/or poorly maintained hearing aids Impoverished educational program Lack of appropriate sensory aids for those with no measureable hearing Insufficient or ineffective parental involvement Additional disabilities Additional problems in learning

None of those factors by itself precludes the possibility of the child learning to talk, but a combination of several of them can mitigate against it.

References Cochlear. (2005). Listen learn and talk: Another cochlear

innovation. (2nd ed.). Alexandria, NSW: Cochlear Limited. Cole, E. B., & Flexer, C. (2007). Children with hearing loss:

Developing listening and talking birth to six. San Diego, CA: Plural Publishing, Inc.

Deconde Johnson, C., & Seaton, J. B. (2012). Educational audiology handbook. (2nd ed.). Clifton Park, NY: Delmar Cengage Learning.

Ling, D. (2002). Speech and the hearing-impaired child: Theory and practice. (2nd ed.). Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing.

Ling, D., & Ling, A. H. (1978, 1980, 1985). Aural habilitation: The foundations of verbal learning in hearing-impaired children. (3rd ed.). Washington, DC: AG Bell Association for the Deaf, Inc.