Guiding Principles and Essential Practices of Listening and Spoken Language Intervention in the School-Age Years

Top Lang Disorders Vol. 38, No. 3, pp. 202–224 Copyright c 2018 Wolters Kluwer Health, Inc. All rights reserved. Guiding Principles and Essential Practices of Listening and Spoken Language Intervention in the School-Age Years

Uma Soman and Mary Ellen Nevins

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

VER the last two decades, more children spoken language (LSL). When given a choice, O who are deaf or hard of hearing (D/HH) a majority of families want their children to are using hearing technologies, such as hear- learn their home language(s) and use hearing ing aids and cochlear implants, and receiv- aids or cochlear implants to develop auditory ing early intervention to develop listening and skills (Alberg, Wilson, & Roush, 2006). The cultural and linguistic diversity of the students whoareD/HHissimilartothatobservedin the larger population, and for a growing num- Author Affiliations: Carle Auditory Oral School, ber of families, the home language might be Carle Foundation Hospital, Urbana, Illinois (Dr Soman); and Audiology & Speech Pathology one other than English or one in addition to Department, University of Arkansas for Medical English. Sciences, Little Rock (Dr Nevins). There has also been a shift in educational The authors have indicated that they have no financial placements such that students’ time is maxi- and no nonfinancial relationships to disclose. mized in general education settings instead of Supplemental digital content is available for this schools or programs specifically for children article. Direct URL citations appear in the printed who are D/HH. Many of these students receive text and are provided in the HTML and PDF ver- sions of this article on the journal’s Web site (www. intervention from interprofessional teams that topicsinlanguagedisorders.com). might include speech–language pathologists Corresponding Author: Uma Soman, PhD, Carle Au- (SLPs), teachers of students who are D/HH, ditory Oral School, Carle Foundation Hospital, 611 W. special education teachers, general educa- Park St, Urbana, IL 61801 ([email protected]). tion teachers, reading specialists, and English DOI: 10.1097/TLD.0000000000000158 language teachers. A certified Listening and

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Spoken Language Specialist1 (LSLS) has expe- children who are D/HH and ELs. To date, lit- rience and expertise in working with students tle has been written on the needs of these who are D/HH and ought to be included on students. This article is offered to contribute the interprofessional team; however, only a to the conversation regarding children who limited number of professionals are currently are D/HH and who are learning at least two prepared and certified for this specialization spoken languages. (Alexander Graham Bell Association for the Practitioners working with students who Deaf and Hard of Hearing, 2017). are D/HH and who are ELs will benefit from Outcomes of students who are D/HH, espe- an understanding of the impact of hearing loss cially those who are English learners (ELs), are on language and academic development con- influenced by a number of intrinsic factors, sidered in the context of dual language learn- some of which are essentially immutable, as ing. There exists a body of knowledge and well as extrinsic factors, over many of which evidence-based strategies that can inform in- there is a degree of control. Importance of tervention for each student who is D/HH to intervention in the first 3 years of life has achieve his or her personal best, including received much attention at the levels of re- those who are ELs. search, practice, and policy. As a result, children who are D/HH currently start their ele- GUIDING PRINCIPLES OF LSL mentary years with varying levels of readiness INTERVENTION to enter kindergarten. Readiness skills often reflect the quality and quantity of early inter- On the basis of a synthesis of knowledge vention services children have received, but from within the field, coupled with insights education and intervention across the school- from our experience working with this pop- age years continue to be critical for build- ulation, we offer five principles for plan- ing language foundations for literacy develop- ning and implementing LSL intervention with ment and for employment and social success school-aged children and adolescents who are in later life. Thus, it is critical to explore the D/HH and who come from culturally and lin- LSL needs of students who are D/HH in the guistically diverse backgrounds. Before ex- context of academic and social development ploring these principles for adoption and im- that occurs during the elementary and middle plementation, impact of hearing loss and its school years. prescribed management are reviewed. In this article, we propose three Profiles The guiding principles and essential prac- of Potential—Keep Up, Catch Up, Move tices of LSL intervention for school-aged chil- Up. These three profiles create a conceptual dren are intended to extend knowledge and nomenclature that describes 5- to 14-year-old skills of practitioners who strive to meet the students based on their needs, growth trajec- varied needs of students who are D/HH and tories, and the family’s desired outcomes. It to encourage sensitivity to cultural–linguistic provides shared terminology for working in variation. In our exploration of these princi- interprofessional teams and with families. In ples, we share examples from our practice as addition, this nomenclature can be applied to well as composite vignettes of students that practitioners might encounter. The five principles are as follows: 1. Intervention maximizes learning to listen 1The Listening and Spoken Language Specialist certifica- and learning through listening. tion is awarded by the Alexander Graham Bell Academy 2. Language and literacy development is for Listening and Spoken Language to individuals with de- foundational to all interventions and tar- grees in audiology, speech–language pathology, or deaf education upon the completion of advanced coursework, geted directly. mentoring, and a passing score on the certification exam- 3. Intervention is individualized, system- ination. atic, and richly multidimensional.

4. Effective intervention is driven by inter- EHDI guidelines” than for the outcomes of professional practice (IPP). children who did not meet the recommended 5. Families are included and empowered timetable (Yoshinaga-Itano, 2003; Yoshinaga- to be partners in listening, spoken lan- Itano et al., 2017). The EHDI bill was reautho- guage, and literacy development. rized in November 2017 and will continue to recommend and support 1-3-6 for infants who Impact and management of hearing loss are D/HH. Application of the five principles requires Per the latest data available, 98.2% of all a deep understanding of the impact of hear- infants born in a hospital are screened for ing loss and the need to manage it effec- hearing loss. Unfortunately, approximately tively. Hearing loss limits auditory access to 30%–40% of children who are referred for speech and language present in the child’s en- additional assessments do not meet these vironment. Prelingual hearing loss has a neg- recommended starting points and are lost ative impact on development of spoken lan- to follow-up due to a variety of factors and guage(s) and can also have a cascading effect mitigating circumstances (Centers for Disease on social–emotional and academic develop- Control and Prevention, 2015). This results in ment. Every state (and territory) in the United unmanaged hearing loss that can have a con- States has an established Early Hearing Detec- siderable negative impact on development tion and Intervention (EHDI) program. Hear- of LSL. Here, unmanaged can refer to later ing screening by 1 month (but preferably be- identification of hearing levels, delayed fitting fore a child leaves the birthing hospital), iden- of hearing technologies, and/or no access to tification of hearing loss by 3 months, and en- skilled professionals to guide family-centered rollment in intervention by 6 months (called intervention. Fortunately, early identification, the 1-3-6 protocol) is the gold standard rec- early amplification, and early intervention can ommended by the National Center for Hear- mitigate the negative impacts of hearing loss ing Assessment and Management and its EHDI (Joint Committee on Infant Hearing, 2007; programs (Joint Committee on Infant Hear- Joint Committee on Infant Hearing and Muse ing, 2007; Joint Committee on Infant Hearing et al., 2013). Generally speaking, approxi- and Muse et al., 2013). This aggressive proto- mately 90% of infants who are D/HH are born col has been developed in response to an un- to families with normal hearing (Mitchell & derstanding of brain neuroplasticity (Dorman, Karchmer, 2004) and, not surprisingly, a vast Sharma, Gilley, Martin, & Roland, 2007; Kral majority of families choose to communicate & Sharma, 2012) and the importance of hear- with their child in the spoken language of ing for typical language acquisition (Fernald & the home (Alberg et al., 2006). Simon, 1984; Kuhl, 2004, 2010; Moon, Lager- Families who choose the spoken lan- crantz, & Kuhl, 2013). guage(s) of the home as the desired outcome A growing number of studies are demon- for their child naturally have a “communica- strating the effectiveness of timely identification match” between their language and the tion and intervention for children who are child’s language. That said, they might be D/HH (Geers, Moog, Biedenstein, Brenner, less knowledgeable regarding issues related & Hayes, 2009; Moeller, Tomblin, Yoshinaga- to hearing loss, device management, and in- Itano, Connor, & Jerger, 2007; Moog & Geers, tentional auditory skills development. When 2010; Niparko et al., 2010; Yoshinaga-Itano, coached by a highly qualified early interven- Sedey, Wiggin, & Chung, 2017). Yoshinaga- tionist specializing in working with families Itano et al. (2017) compared the effects of ad- of children who are D/HH and are developing herence to the 1-3-6 protocol on vocabulary LSL, the opportunity to jump-start the learning development of children who are D/HH and journey and positively influence its trajectory discovered that “vocabulary quotients were is eminently possible. If the interventionist, significantly higher for children who met the although specialized in developing LSL is not

fluent in the family’s spoken language, the families and practitioners to work together to child’s language acquisition process may be help a student Keep Up with typically hear- impacted. ing classmates, Catch Up to same-aged class- Without the linguistic skills and/or the cul- mates, or Move Up to attain the next appropri- tural competence to coach families directly in ately targeted milestone in development. The the home language and understand the influ- following descriptions may clarify the difference of the home language on learning spo- ences between each of the suggested perfor- ken English not only are practitioners at a dis- mance profiles. advantage but so too are children and families. One must consider the “double-challenge” ef- Keep Up fect on children who are both D/HH and ELs. Students who are challenged to Keep Up Given the linguistic diversity of the families have experienced early identification and and children served, and the limited number intervention resulting in “at or near” age- of qualified LSL professionals overall, the chal- appropriate listening, speaking, and reading lenge of providing excellent early interven- abilities. They must continue to develop skills tion needs to be addressed on a case-by-case, in order to keep up with the ever-expanding location-by-location basis to design the best linguistic and academic expectations of their service delivery plan by an interprofessional grade level and typically hearing classmates. team of practitioners. Regardless of the language in use, practitioners who commence in- Catch Up tervention with dedicated knowledge, skills, and dispositions for working with children Students who require support to help them who are D/HH and their families are poised Catch Up are those who have benefitted for the greatest success (Sass-Lehrer, Moeller, from LSL intervention but likely have had & Stredler-Brown, 2015). an idiosyncratic challenge (late identification, poorly fit device, limited intervention, etc.) Profiles of potential as part of their early development. Most of- Given the variety of factors that influence ten these students have made steady progress a child’s early intervention journey, children over the years but do not yet have age- who transition from early intervention into appropriate listening, speaking, and reading the school environment might be starting skills. Each child will likely need intense inter- at different levels of proficiency in their lis- vention (from an LSL practitioner) to develop tening skills, home language(s), and social– age-appropriate LSL skills to catch up with his emotional development. Practitioners should or her classmates. consider each student uniquely and identify strengths and areas of needs in each domain Move Up to plan intervention. However, we suggest Students who are encouraged to Move Up that students who are D/HH might be char- are those who, in addition to being identi- acterized by one of three possible profiles of fied with hearing loss, have secondary diag- potential as they move into traditional educa- noses such as visual impairment, autism spec- tional settings from early intervention. trum disorder, learning disability, etc. In these Conceptualizing these loosely organized situations, the student might exhibit substan- profiles of potential might assist practitioners tial delays in one or more areas of develop- in developing and targeting objectives that are ment and/or academic achievement. These challenging but proximal and achievable for children can still make progress with appro- the students for whom they are written. Us- priately selected and functional listening and ing terms that emphasize an active, general language intervention; in so doing, engage- learning outcome desired for students in each ment with their family and their community group, these profiles of potential can guide is enhanced.

Principle 1: Intervention maximizes perception of vowels in their native language learning through listening by 6 months (Kuhl, 2004; Kuhl, Williams, The first principle focuses on facilitating Lacerda, Stevens, & Lindblom, 1992). By language and literacy development through 12 months, infants with typical hearing systematic auditory skill development. This can discriminate the consonants of their assumes access to the speech spectrum native language (see review by Kuhl, 2004). through well-fit and consistently worn Furthermore, infants demonstrate familiarity hearing technology—hearing aids, cochlear and preference to the sounds of their native implants, and/or bone-anchored hearing language versus non-native language (Cheour devices. Research suggests that even a et al., 1998; Rivera-Gaxiola, Silva-Pereyra, & mild degree of hearing loss is educationally Kuhl, 2005; Tees & Werker, 1984). significant and can disrupt the integrity of This phenomenon of perceptual narrow- auditory input, leading to negative impact ing or perceptual attunement is fundamen- on development of auditory skills essential tal to native language acquisition (Maurer & for language acquisition and language com- Werker, 2014). Infants in bilingual or multi- prehension (Bess, Dodd-Murphy, & Parker, lingual home environments show some dif- 1998; Tomblin et al., 2015). ferences, including later demonstration of attunement to the phonemes in the home language (Byers-Heinlein & Fennell, 2014). Maximize audition However infants and toddlers who have In typical development, hearing is a first- meaningful exposure to the home languages order event in the process of language ac- demonstrate perceptual attunement to them quisition (Cole & Flexer, 2015). However, (Bijeljac-Babic, Serres, Hohle,¨ & Nazzi, 2012; speech perception is an audiovisual activity Burns, Yoshida, Hill, & Werker, 2007; Garcia- in which typically developing infants are at- Sierra et al., 2011; Weikum et al., 2007). tending to the sounds and rhythm of the It is important to note that this protracted language along with observing the lip move- timeline is not a delay caused by being in a ments of their caregivers (Kuhl & Meltzoff, bilingual environment but rather an alterna- 1982; Lewkowicz, 2010). Through a series tive timeline of development of simultaneous of maturational processes combined with lin- bilingualism. guistic experiences infants learn to detect These findings suggest that babies who are and discriminate the sounds of their na- born with congenital hearing loss (present tive language (Kuhl, 2004; Maurer & Werker, at birth) will have lost valuable listening 2014). Attuning to the sounds of one’s na- time before they take their first breath and tive language begins in utero and is evident will have much to decipher when they soon after birth. Newborn infants show a gain access to audible speech and language preference for listening to speech, particu- through their hearing technology. It has been larly the language they heard in utero, com- proposed that even those who are using pared with nonspeech stimuli (Vouloumanos hearing technology experience some degree & Werker, 2004, 2007) and compared with of auditory deprivation (Conway, Pisoni, & speech sounds from an unfamiliar language Kronenberger, 2009), which might impact (Moon et al., 2013). Infants can discriminate neural development. Because auditory access between languages from different rhythm through hearing technology does not exactly classes, for example, English from French by replace natural acoustic hearing, it might alter 3 months (Nazzi, Bertoncini, & Mehler, 1998). how the brain processes and lends weight to At the segmental level, infants can discrim- the meaning of auditory input in the context inate between vowels from native and non- of other sensory experiences (Gilley, Sharma, native languages (e.g., German vowels /U-Y/ & Dorman, 2008; Sharma, Gilley, Dorman, & and English vowels /i-a/) by 4 months (Polka Baldwin, 2007). The impact of early auditory & Werker, 1994) and demonstrate categorical deprivation and altered auditory input is

currently under investigation, so mindful ming and upgraded assistive listening technology. practitioners should be alert for additional This adjustment in Alex’s access to the auditory sig- scientific evidence that will better inform nal subsequently maximized his learning through their practices and expectations. listening. When providing LSL intervention to stu- Targeting the hierarchy of listening dents who are D/HH, practitioners should skills note that, although hearing technology provides access to sound, it is not perfect. Stu- Upon receiving hearing technology, most dents might not attend to their auditory envi- children have to learn to listen to the audi- ronment all the time and might only tune in tory input to make sense of what they are when they are directed. For beginning listen- hearing. This process typically involves learners (e.g., students who receive their hearing ing to detect, discriminate, identify,andcom- technology at a time coinciding with enroll- prehend information presented in an auditory- ment in school), the auditory stream might be only manner. This hierarchy of listening skills overwhelming and indecipherable, necessitat- (Erber, 1982) provides a roadmap for devel- ing need for direct instruction. It is important oping these skills and maximizing learning to gauge the audibility or auditory benefit de- through teaching children directly how to rived from the hearing technology. Questions listen. to ask include the following: Can the student Erber’s (1982) seminal work with children hear all the speech sounds in his or her spo- with all degrees of hearing loss led to con- ken language(s)? Does the student have ade- ceptualization of four distinct stages of au- quate access to hear the difference between ditory skill acquisition, using terms that al- phonemes that vary by a single feature such low professionals to communicate precisely as manner (e.g., /d/ vs. /n/), place (e.g., /k/ what a student is capable of doing using hear- vs. /t/), or voicing (e.g., /b/ vs. /p/)? How ing alone—detection, discrimination, identi- well does the student hear in a noisy situa- fication,andcomprehension.Whenataskis tion? Consultation and collaboration with a auditory-only, no visual cues are available to pediatric audiologist or an educational audiol- the listener, thus truly ascertaining the contri- ogist can lead to an appropriate audiological bution of the hearing technology to learning management plan that is attuned to the chang- auditorally. Each of the four stages of the au- ing listening needs of students and maximizes ditory skill hierarchy is elaborated as follows. auditory access in all learning environments. Consider the following scenario of a third- Detection grade student, Alex, who is on a Catch Up This is the most basic auditory skill where trajectory: the listener simply indicates awareness that a sound is present (or absent) and is the founda- Alex was adopted at 18 months and identified as tion upon which more sophisticated auditory having severe hearing loss at 24 months. He wore responses build. Because detection is required bilateral hearing aids and received specialized infor all later stages of auditory skill develop- struction in an early childhood program for stu- ment, early fitting of hearing devices is essen- dents who are D/HH. By the end of second grade, tial to jump-start auditory learning. Determin- Alex had near age-appropriate language scores and ing a child’s unaided detection level is the entered third grade in his neighborhood school. entry point for choosing the hearing tech- He received support from a teacher for students nology that will make spoken language input who are D/HH, as well as from an SLP and an educational audiologist. Three months into the school audible. For school-aged students who are year, Alex began complaining about the classroom D/HH, it is easy to confuse detection with being very noisy during group work. After observa- higher levels of auditory skill; it is all too tions and assessments, the educational audiologist common for a teacher to report that a child is recommended a change in hearing aid program- hearing when he or she responds to a passing

fire truck or a voice command that simply propriate fit and function of hearing tech- gets the child’s attention that something nology. Speech perception is strongly linked is happening. For example, during quiet to speech production (Eisenberg, 2007), so reading time, the teacher may indicate that understanding a student’s speech perception it is “time for gym.” The developing listener, scores is essential to planning and implement- however, may only hear the teacher’s voice ing articulation therapy. Daily and routine lis- coming out of the quiet and look up to see tening checks are essential to ensure that a what the rest of the students are doing and child’s access and baseline functional perfor- take a cue from their actions. These are mance is the starting point of every listen- examples of sound-only detection. ing day and therapy session. The Ling Sound Check (Ling, 2006) is a quick and easy task Discrimination that is used for this purpose; a child never The ability to identify whether two stimuli outgrows the need for a check against his are the same or different is discrimination. or her own standard performance. Deviation Generally speaking, this is not a skill that is from expected performance may be an indi- targeted separately in instruction but rather as cator of device malfunction or change in hear- part of an intervention strategy on the road to ing status; teachers and SLPs are encouraged fine-tuning the auditory skills required at the to learn more about why and how to per- level of identification. Typically implemented form the Ling Sound check. For more infor- after the student has misheard, this same– mation about speech perception assessments, different judgment ability in more advanced see Supplemental Digital Content A (available authentic communication tasks will assist the at: http://links.lww.com/TLD/A59). young listener in knowing that dog and frog arenotoneandthesameanimal;thewords Identification book and books differentiate in number; and The skill in which a stimulus is recognized in and on represent varying spatial relation- and acted upon is identification.Thestu- ships. Discrimination tasks without an under- dent’s response, either motoric or linguistic, lying language or literacy objective are not provides a window into the hearing brain. generally targeted for instruction. However, For the young listener, examples of identi- they might be useful as an intervention probe fication include recognition of receptive vo- to determine what the student has heard. For cabulary and responses to language that can example, in a phonological awareness task be ascertained through an auditory-only pre- combining onsets and rimes, a student may sentation. When directed to pick one banana, incorrectly create the word big when /d/ and two oranges, or five grapes, a preschooler ig are presented. In this case, a quick check to who can select the ingredients of a fruit salad determine whether the student can discrimi- (given an auditory-only presentation of the nate between /d/ and /b/ will drive the next item) is demonstrating auditory identification. step. If the student can discriminate between For the older listener, responding correctly to the two phonemes, saying big instead of dig an auditory-only prompt, spoken without vi- might be related to articulation errors or even sual/lipreading cues, for example, “point to vocabulary limitations. Australia on the map,” is also an example of Practically speaking, the discrimination the skill of auditory identification. skills of a student who is D/HH are greatly Additional tasks that require identification influenced by the programming of the hear- might include writing math problems in a ing technology, which should be fit to en- listening-only condition or repeating core sure adequate access to the speech spectrum. statements of fact from the science unit as pre- The audiologist should be conducting peri- sented with no visual cues. Often times, inter- odic speech perception testing at the sound, ventionists present closed sets of all possible word, and sentence levels to ensure the ap- responses as an instructional/interventional

strategy. Limiting the possible responses and Gaffney (2015) describe these strate- assists the student in being successful with gies in an open-source document for which auditory tasks. Closed sets support the a link is provided in Supplemental Digital development of increasingly sophisticated lis- Content A (available at: http://links.lww.com/ tening skills overlaid onto an ever-expanding TLD/A59). language repertoire. However, if a student For children who are D/HH and EL, the is unable to complete a task even with full same hierarchy of listening skills applies. If access to auditory and visual cues, it is highly proficiency in the home language is a desired unlikely that the student will be able to outcome, practitioners and families could do so in an auditory-only condition. This is work toward developing auditory compre- especially noteworthy for students trying to hension of the home language as well as En- Catch Up who rely on continued listening glish. This will allow students to participate and language intervention/education because more fully in their cultural community as well of their idiosyncratic needs. In essence, the as at school. practitioner guides the student through a se- quential ratcheting of auditory competence in Maximize device wear time the context of an expanding linguistic skill set, Finally, the principle of maximizing (spo- particularly as the language of instruction be- ken language) learning through listening de- comes more complex and learning advances. mands consistent use of hearing technology. Wear time is a factor that contributes to any Comprehension student’s improved performance with hear- The most sophisticated level of auditory ing technology. It is within control of the skill development is comprehension.Itis family, SLPs, and teachers, but it is not al- considered by many to be the final outcome ways easy to ensure. Internal data logging fea- of LSL intervention and education. The tures in both hearing aids and cochlear im- interrelationship of listening and language plants can now help monitor wear time of continues to impact ability, but simply the device. The cumulative effects of constant stated, auditory comprehension suggests the wear time contribute to better auditory per- capacity to do more than just identify or formance with hearing devices (Walker et al., name the linguistic stimulus. Instead, the 2013, 2015). Another issue related to learn- listener is required to act upon or respond ing through listening is that of listening fa- to the auditorally presented message. For tigue. Recent studies in students with hear- example, when asked a question (through ing loss (Bess, Gustafson, & Hornsby, 2014) audition alone) “What are the stages of the underscore the effort that is required to be water cycle?” the student who understands an active auditory participant in classrooms. the question does not simply repeat back the For more information about listening fatigue stimulus. Instead, he or she responds with the in students who are D/HH, see sources in answer to the inquiry by saying, “evaporation, Supplemental Digital Content A (available at: condensation, and precipitation.” Thus, the http://links.lww.com/TLD/A59). student demonstrates auditory comprehension, along with memory and retrieval of facts Principle 2: Language and literacy learned previously or available in the text. development is foundational to all In pursuing the development of the audi- intervention tory skills of detection, discrimination, identi- After families have chosen spoken language fication, and comprehension in parallel with as the primary mode of communication and the development of increasingly sophisticated learning for their child, all LSL interventions spoken language ability and literacy skills, the for school-age children should be guided by practitioner is encouraged to utilize strate- and focused upon the development of lan- gies that are part of LSL practice. Fickenscher guage and literacy skills essential for achieving

academic proficiency, social competence, features of language and speech, but develop- and other desired outcomes. The construct ment of spoken language in early childhood of literacy encompasses the ability to listen, years and literacy in the school years must be speak, read, and write using a literate style. fostered through intentional intervention for Childhood hearing loss can have a nega- these children. tive impact on development of the essentially Thus, it follows that the goal of LSL inter- interdependent skills of listening, speaking, vention is acquisition and maintenance of age- reading, and writing. For example, a student appropriate auditory, language, speech, aca- using hearing aids might not clearly hear the demic, and social skills. Historically, students regular past tense marker -ed and understand who are D/HH have demonstrated deficits that it denotes an action that has happened. in reading (Traxler, 2000) and other aca- It is then likely that the student does not demic achievements. However, a review of use -ed in his or her spontaneous spoken more recent literature indicates that many language and does not attend to this mor- preschool and school-aged students who are pheme when presented in a text. It might D/HH and receive timely and effective LSL follow that this absent morpheme will not intervention can develop age-appropriate vo- appear in his or her written language. For cabulary (Yoshinaga-Itano et al., 2017), spo- students who are D/HH, deficits in oral vo- ken language and literacy (Geers et al., 2017; cabulary and morphosyntactic development Mayer & Trezek, 2018), and academic skills can impact literacy development but can (Antia et al., 2009). be addressed through intervention (Gross & In typical development, quality and quan- Robertson 2017). Literacy instruction and in- tity of language input, along with caregiver tervention that take into account the unique engagement, are factors that influence fu- impact of hearing loss are well within the ture language outcomes. Children who are in scope of practice of the LSL professional, as language-rich environments, engage in mean- well as the SLP (American Speech-Language- ingful conversations, and participate in shared Hearing Association [ASHA], 2001). A collab- book reading with caregivers have a strong orative approach for implementing interven- foundation for language and literacy. The tion is recommended. Within discussion of same is true for children in bilingual home en- this principle, we focus on the development vironments in which they are exposed to two of vocabulary and complex language while or more languages and developing them si- relating it to development of all aspects of multaneously. For children who have a strong literacy. foundation in one language and then learn a In typical development, spoken language second language, there might be a protracted acquisition relies on optimal perception of learning period but the strong foundation in the language(s) in a child’s environment, the first language likely assists in learning the as provided through meaningful linguistic second language. interactions with caregivers (Hirsh-Pasek & Learning two languages that differ in modal- Golinkoff, 2012; Konishi, Kanero, Freeman, ity such as American Sign Language and spo- Golinkoff, & Hirsh-Pasek, 2014; Ram´ırez- ken English can be considered bilingual, and Esparza, Garc´ıa-Sierra, & Kuhl, 2014). As it can demonstrate certain features of spoken stated previously, congenital hearing loss not bilingualism such as code switching and in- only impacts the development of listening, serting vocabulary from one language in the language, and speech skills but also has an syntactic frame of the other. However, such indirect effect on development of academic instances are beyond the scope of this article, and social skills (Antia, 2011; Antia, Jones, which focuses on developing two or more Reed, & Kreimeyer, 2009; Dammeyer, 2010; spoken languages, which often include sce- Moeller, 2007; Moeller et al., 2007). Hearing narios in which the student is an English lan- technology can restore access to the auditory guage learner.

Given the importance of having a strong of words are learned from direct instruction language foundation in early childhood, re- (Bloom, 2002; Christ & Wang, 2010). cent research and public policy are focused For many students who are D/HH, develop- on developing interventions such as Thirty ing vocabulary can be challenging. The result Million Words Initiative (Leffel & Suskind, is a vocabulary that is limited in size, breadth, 2013; Suskind et al., 2016) and “Reach Out and depth (Lund, 2016). For students who are and Read” (Weitzman, Roy, Walls, & Tom- D/HH and EL, learning words for the same ob- lin, 2004; Zuckerman & Khandekar, 2010). ject and concept across languages can present These programs are being implemented to an additional challenge. A student who speaks close the language gap for children in mono- Arabic at home might have a majority of food- lingual, bilingual, and/or low socioeconomic and family-related vocabulary in Arabic but environments. not in English, and vice versa for vocabulary Researchers who work with students who related to academics. Deficits in vocabulary in are D/HH are developing similar interventions one or more languages will likely impact per- that take into account the impact of hearing formance in the classroom as well as social loss in addition to the demographic factors. interactions at school and create confounding Cruz, Quittner, Marker, and DesJardin (2013), factors during assessments. for example, identified parallel talk, open- Elementary school students are expected ended questions,andexpansion as high- to acquire at least 8–10 new words per week level language facilitation strategies that con- (Biemiller, 2003; Biemiller & Slonim, 2001; tributed to growth in expressive language of Nagy & Anderson, 1984) through interactions students who are D/HH, irrespective of the with individuals, engagement with texts, family’s socioeconomic status. Currently, re- and incidental learning. All students need to search on the development of students who expand the size, breadth, and depth of their are D/HH and EL is sparse. That said, under- vocabulary to meet the demands of academic standing the overlap between language in- instruction. Many education and language tervention strategies for D/HH and EL can professionals are aware of the work of Beck, provide guidance when developing age- and McKewon, and Kucan (2013), who classify stage-appropriate targets and is discussed as vocabulary into three tiers. Tier 1 vocabulary follows. represents basic words or the first words for concepts, for example, baby, mommy, big, happy, like. Tier 2 vocabulary represents Vocabulary development words frequently used in mature language, for and intervention example, infant, parent, enormous, joyful, Learning the words of a language is fun- adore, and are encountered in a variety of damental to the comprehension and expres- contexts, especially in grade-level reading sion of thoughts and ideas. Whereas some materials. Tier 3 vocabulary represents words words might be intentionally taught to young that are rarely used and mostly in specific children by their families, a vast majority of contexts, for example, sedimentary, ento- words are learned incidentally by encounter- mology, excavate. Tier 1 vocabulary might ing them in meaningful natural contexts. For be sufficient to have a basic conversation in example, a typically developing preschooler order to meet needs and wants, but Tier 2 vo- might know the words spoon, fork,andknife cabulary is essential for learning and engaging through intentional instruction by families but in an exchange of ideas as students and adults. might learn the word chopsticks in the con- Limited vocabulary, especially Tier 2 vocab- text of eating Chinese food at a restaurant. ulary, can impact learning of concepts and In fact, a large majority of words acquired new vocabulary for all students but especially in early childhood are learned through inci- for those who are D/HH. Consider an ele- dental learning whereas only a small minority mentary school scenario in which the teacher

states, “Texts that are make-believe are fic- ulary infrastructure that assists in later access tion, and those that are real are nonfiction.” to previously learned words. Whether new The key words in this sentence are texts, words are learned through direct instruction make-believe, real, fiction,andnonfiction. or incidentally, incorporating them into the Typically developing students might be famil- existing semantic organization is essential for iar with the words make-believe,andreal, efficient retrieval. Consider the following sce- making it possible for them to deduce what nario of a fictionalized middle school student, fiction and nonfiction mean. However, the a bilateral hearing aid user, who is on a Keep student who is D/HH might not fully under- Up trajectory. stand what make-believe and real mean. If Jayla knows the words electricity from a lesson not, this student will not be able to grasp the on Benjamin Franklin and electrician from a vo- meaning of these terms as quickly as class- cabulary list related to occupations. As Jayla pre- mates. Many state curricula expect students pares for a science unit on modern technologies to master these concepts by the end of first and engineering, she learns the words electric and grade. One can imagine how difficulty with electronic. It is important to consider how she in- these seemingly simple vocabulary and con- corporates and organizes these words in the concepts can impact future learning of concepts, text of her existing vocabulary. Does she have ad- such as genre and realistic fiction, putting the equate word study skills to understand that all of student even further behind. these words have a common origin and then ex- To advance vocabulary development, prac- tend it to the word electron but not election?How titioners must be proactive in identifying con- do deficits in understanding prefixes, suffixes, and grammatical morphemes impact listening, speak- textualized vocabulary and concepts (in ad- ing, reading, and writing? dition to those identified by the Teacher’s Guide) that are not only important for under- Students who are D/HH are often catching standing a particular text but also applicable up to what their classmates might know and in other contexts. For example, learning the then trying to learn additional new words. words destination, breathtaking,andtower- Thus, efficiency in teaching vocabulary and ing,inpreparationforanunitonnational helping situate it in an existing semantic map parks and landmarks, will not only facilitate is necessary on the practitioner’s part. Con- learning of the target content but could also sider teaching the word habitat.Itcanbe lead to more precise word choice when shar- taught by pairing an unknown word with ing commentary about story settings or even a known word and creating a “vocabulary family travel. sandwich” and acoustically highlight the tar- Previewing a classroom lesson during an get word during instruction. “Habitat is the intervention session and emphasizing the vo- house or environment that people or animals cabulary and concepts within the unit can live in. Habitat. The camel lives in a desert level the playing field for learning and pre- habitat.” In this brief interaction, the prac- pare the student to engage in academic con- titioner repeats the target word three times versations with his or her classmates. Experi- within a meaningful context and provides encing the information a second time during clues to situate it in an expanding semantic classroom instruction might allow the student map. to use the target vocabulary when participat- A general rule of thumb is that typically ing in the lesson. For many students who are developing children need to hear a word D/HH, previewing target vocabulary can be 15–20 times in order to learn it. It has been incorporated as an objective in the Individu- proposed that students who are D/HH might alized Education Plan (IEP) and addressed by need up more repetitions for learning the teachers and SLPs. same word. Practitioners should consider Unfortunately, simply encountering new creating multiple opportunities for exposure words is not sufficient to create the vocab- to relevant words. For example, repeated

exposure to the word camouflage in re- in which students might require intervention sponse to a child’s saying “I have soldier for a longer duration than they might in vo- pants and soldier backpack” could support cabulary or pragmatics (Ganek et al., 2012; meaningful learning of age-appropriate lan- Moeller et al., 2007). Difficulty with com- guage. Taking the opportunity to understand prehension or expression of complex syntax and learn these precise words can lead to in spoken language can translate into diffi- more sophisticated language, avoiding the culty in reading or writing texts containing perception of the students as being childish sophisticated language. Consider the follow- or immature by adults and/or peers. ing prompt to write an alternate ending to the story, for example, “What else could Cade Complex language development have done to solve the problem of the miss- and intervention ing birthday present?” Student responses re- Vocabulary intervention can propel a quire the understanding of highly complex student’s understanding and use of age- language, including the modal of possibility appropriate vocabulary in academic domains, (could) and perfect tense (have done)to but it is incomplete without adequate atten- communicate something that did not hap- tion to mastery of complex syntax. Stringing pen but could possibly have happened in a together a few words or using simple sen- new ending. One resource that can assist the tences with a single verb phrase may be suffi- practitioner in implementing intervention for cient to communicate basic needs and wants, syntactic development in a systematic man- but complex syntax (i.e., sentences with one ner is the Cottage Acquisition Scales for Lis- or more clauses, each with its own verb tening, Language, and Speech (CASLLS). For phrase) provides an efficient way to commu- more information about this resource, see nicate multiple ideas and relationships among Supplemental Digital Content A (available at: them. For example, a routine direction such as http://links.lww.com/TLD/A59). “Before you go to recess, complete the word problems on page 65” can be challenging if Literacy development and intervention the student does not understand the mean- In addition to developing vocabulary and ing and function of the conjunction before complex language, students who are D/HH or if the student applies the order-of-mention need direct instruction in phonological aware- strategy when interpreting the given direction ness, phonics, morphological awareness, and starts to leave for recess. If the student sight word reading, and related concepts. In- does not follow the direction, it might be per- struction and intervention related to reading ceived as “misbehavior” or inability to follow and writing are a broad topic, which is beyond directions when, in fact, it might be neither. the scope of this article focusing on princi- A teacher’s redirection (or perhaps even chas- ples of LSL intervention. Gross and Robertson tisement) for failure to complete the task as (2017) provide a detailed overview of literacy assigned could be confusing, disappointing, development of students who are D/HH. A or even embarrassing to the student. thorough discussion of literacy interventions Research studies demonstrate that some for students who are D/HH can be found in students who are D/HH have difficulty acquir- Robertson (2014). In addition, in this special ing age-appropriate syntactic skills (Cannon issue, Alfano and Douglas (2018) discuss lan- & Kirby, 2013; Ganek, McConkey Robbins, guage and literacy development for children & Niparko, 2012; Moeller et al., 2007). Mor- who are bilingual. phological markers such as plural -s or tense markers such as -ed and -ing consist of high- Special considerations for students frequency consonants and rely on adequate who are D/HH and EL auditory access and auditory skills. As a re- A recent review of guidelines for ac- sult, syntactic development could be an area commodating to the needs of ELs in the

elementary classroom yields a list of tips that, worthy targets for intervention; thus, the prac- not surprisingly, parallels many of the same titioner may wish to consider the role of strategies recommended for students who are words such as these as part of a total language D/HH in the mainstream. These recommen- plan. Similarities between recommendations dations include general instructional princi- for students who are D/HH and are ELs are ples, specific linguistic guidelines addressing apparent in Table 1. vocabulary, syntax, and nonliteral language, In summary, hearing loss influences how as well as delivery of instruction. a child learns to listen, speak, read, and Whether students are D/HH, ELs, or both, write. Facilitating the development of age- and one important suggestion is to consider the grade-appropriate language and literacy skills interplay between the content and language begins with early intervention but continues used to convey important subject matter con- throughout the school years so that the stu- cepts. During classroom instruction, inabil- dent will be college or career ready. Thus, all ity to derive the correct meaning from a interventions provided to students who are complex sentence can limit comprehension. D/HH or D/HH and EL by any member of the For example, consider the following sentence interprofessional team are rooted in and foster that might be found in a science text de- the growth of listening, language, and literacy. scribing erosional effects and the comprehension skills necessary for understanding Principle 3: Intervention is the language: “Repeated swings in tempera- individualized, systematic, ture can also weaken and eventually fragment and richly multidimensional rock, which expands when hot and shrinks Teachers and therapists who are creating when cold.” Although concepts included in learning objectives for IEPs and providing in- this sentence may be within the cognitive ca- tervention to students who are D/HH in a pacity of the student, unfamiliar vocabulary school setting take into account the child’s and the grammatical structure may mask its hearing history, auditory access, and home comprehensibility. It stands to reason, then, language and present levels of performance in that when subject matter is newly presented, language, literacy, and other academic areas. preteaching of the vocabulary and simplifica- Whereas the first two principles focus on the tion of the grammatical frame may assist a what and why of LSL intervention, this third student in grasping the essence of the core principle focuses on the how. That is, inter- content. vention should be individualized to the One recommendation for practitioners student’s unique learning profile and desired working with students in classroom who are outcomes, utilizing a systematic approach D/HH is to follow the EL guidelines offered in that takes into account a hierarchy of skill de- Teacher’s Guide for a particular academic sub- velopment in language, literacy, and academic ject. In addition to the precise content vocab- areas, and is richly multidimensional so ulary specified by the topic under study, there as to target objectives from multiple domains are many Tier 2 vocabulary words that appear within the same activity or lesson. in text with the assumption that they are al- ready present in the lexicon of the typical stu- Individualized intervention dent. Seemingly innocent words such as in- When working with a student who might dividual, regularly, separate,andconstant be on a Keep Up, Catch Up,orMove Up may be found as modifiers to subject matter trajectory, practitioners are charged to iden- words but may be virtually meaningless to an tify challenging but achievable goals across EL student who is D/HH who then overlooks all domains of knowledge and skill building. the important information such words con- Goals and activities that take into considera- tribute to understanding the text. The high tion child-specific factors of hearing and learn- utility of knowing such words makes them ing create the desirable difficulties that make

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

Domain Students Who Are D/HH Students Who Are ELs

General instruction Weigh cognitive load against Balance content and language linguistic density Teacher–student Provide wait time for processing Offer opportunities for spoken instructional turns of teacher question language practice Assessing Ask student to repeat or Check for understanding by comprehension summarize the lesson with asking the student to tell how random checks of all students he or she will approach an so as not to target the student assignment who is D/HH Vocabulary Consider lesson preview Encourage word learning, highlighting unfamiliar words especially in context Language Build receptive language Provide a language model and structure/syntax understanding and transfer to recast for syntactic complexity expressive output Nonliteral language Be on the lookout for idiomatic Make ﬁgurative language explicit language and probe for the student’s understanding Speed and prosody Speak slowly and clearly; use Don’t speak too fast; emphasize of speech acoustic highlighting important concepts

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

true accomplishment motivating for the stu- domains. Consider the following scenario of dent. In so doing, any child has the opportu- a 5-year-old kindergartener, Ruby, who is on nity to develop what Dweck referred to as a a Move Up trajectory. growth mind-set as opposed to a fixed mindset (Dweck, 2007). In the former, children Ruby has only recently begun using bilateral cochlear implants and has substantial needs in the adopt a “can do” attitude and celebrate effort domains of audition, speech, and language. She and the achievement that come from thought- demonstrates age-appropriate cognitive and motor ful strategy selection and steady progress to- skills. As her classmates learn about various animal ward a goal. Without question, this is an im- habitats, Ruby is learning the names of animals. portant disposition to learning for all children, As detailed by Rosenzweig (2011), when there is especially those who are D/HH. When goals a big difference in chronological age and hear- of intervention are targeted for students who ing age, providers must consider age-appropriate are D/HH as individuals, following the mile- learning activities, even though the targeted audi- stones of development in a systematic man- tory and/or language goals may be rudimentary. ner, and customized to place learning well Ruby might benefit from learning names of ani- within the zone of proximal development mals (a stage-appropriate skill) through dramatic play (an age-appropriate activity) facilitated by the (Vygotsky, 1978), it is more likely to ensure provider within the general education setting dur- the success that serves as the motivation for ing a “push-in” session. Similarly, in an individual continuing to “do hard things.” intervention session, Ruby could continue to learn Typically, students who are receiving LSL animal names through reading a book such as Dear intervention have deficits in some but not all Zoo or singing Old McDonald Had a Farm.

Given the reality of scheduling constraints Richly multidimensional intervention in a school setting, it is often incumbent upon For most students who are D/HH, practi- the providers to deliver intervention in small tioners must keep up with academic content group settings. We propose that it is possi- while backfilling the idiosyncratic holes in lin- ble to provide individualized LSL intervention guistic, auditory, and critical thinking skills. even when working with children who are at With the focus on closing the language gap, different ages and stages in development. For it is not feasible to target only one objective example, Ruby could be paired with her class- in one lesson. There is an economy of es- mate Ishan, who is on a Catch Up trajectory. sential function when each of the student’s Ishan’s language goals include expanding vo- needs is considered in a rich interventional cabulary and increasing syntactic complexity. plan that targets many objectives in a single, In keeping with the animal habitat theme, well-designed session. while looking through a picture book, the For example, it is possible to include audi- provider could ask Ruby, “Where is the pig?” tory, receptive, and expressive language (in- and then ask Ishan, “Where does it live?” with cluding form, content, and use) targets in sev- the expected response of “the pig lives in the eral activities within a session. For example, sty.” In this scenario, both students are receiv- as a companion to a classroom unit on the ing targeted intervention, even though they environment, a student who is D/HH may be have different language goals. In addition, asked to categorize items as being recyclable there is an opportunity to work on social skills or not when given an auditory-only presenta- as well as literacy skills through dialogic read- tion of a list, recall the sequence of events out- ing (DesJardin & Ambrose, 2010; DesJardin, lined in a trade book about one town’s efforts Ambrose, & Eisenberg, 2009; DesJardin et al., to recycle, and create a television commercial 2017). that promotes recycling. Each of these activities targets listening, language, and vocabulary Systematic intervention objectives as well as writing and pragmatic goals that are embedded into this content- In addition to developing individualized in- related and theme-based LSL intervention. For tervention, it is important to contextualize the practitioner who is classroom-based, there selected targets within a hierarchy of devel- are resources within the Teacher’s Guide of opment. For example, 6-year-old Vincent has most curricula that can be consulted to assist progressed from “want apple” to “I want an in planning functional intervention that meets apple” to “May I have the big, red apple?” The the needs of students who are D/HH and who next step in his syntactic development could also are ELs. be the use of relative clauses and prepositional phrases, for example, “May I have the big, red apple that is on the counter?” Note that in Principle 4: Effective intervention is addition to development of complex syntax, driven by interprofessional practice the provider has to work on developing a vari- Recall that only a limited number of ety of syntactic elements, for example, prepo- teachers and SLPs have specialized training in sitions to be used in prepositional phrases, working with students who are D/HH and use starting from early emerging prepositions, in LSL, perhaps related to the fact that students or on, to the next level of beside or above. who are D/HH are part of a low-incidence Attention to systematic progression of skills population. Within the last decade, more is also relevant for audition, vocabulary, liter- practitioners have been able to obtain a post- acy, cognition, and even social skills develop- graduate certificate as a Listening and Spoken ment. For more information on resources, see Language Specialist Certified Auditory Verbal Supplemental Digital Content A (available at: Therapist or Educator (LSLS Cert AVT or Cert http://links.lww.com/TLD/A59). AVEd) through the Alexander Graham Bell

Academy for Listening and Spoken Language even an educational (sign) interpreter to as- (www.agbell.org/teach). sist in providing access to higher level cur- Currently, there are approximately 800 cer- ricular instruction. Catch Up students might tified LSLSs worldwide. A majority of these require these same personnel, but the team practitioners reside in the United States and could also include a reading specialist and a provide intervention in English (Guignard, bilingual education specialist to meet the stu- 2017). Of these practitioners, 43% are teach- dent’s individual learning needs. As another ers of students who are D/HH and 39% are example, students presenting with a Move SLPs. Most are intersecting with students who Up profile may require a team that goes well are D/HH and/or ELs in public schools, private beyond the core members indicated earlier. special education programs, or private prac- For such students, additional team members tices. The LSLS designations indicate that the might include a neurologist, a special edu- individuals who have earned them have expe- cation teacher, an occupational therapist, a rience and expertise in developing LSL skills school psychologist, and perhaps a vision spe- in students who are D/HH. They have com- cialist to help meet the student’s multiple pleted a rigorous certification process that in- learning challenges. cludes 900 hr of practice, continuing education, mentoring with an established LSLS, and Working as a team knowledge and skills examination. Today’s interprofessional collaborative pra- In the absence of this specially certified in- ctice guidelines state explicitly that providers dividual, it is well within the scope of practice and families/caregivers work together to im- for SLPs to address the needs of the school- prove outcomes and quality of care and edu- aged population of students who are D/HH. cation of their students. According to ASHA Given a strong base in language acquisition, an (2017), IPP occurs when multiple service understanding of the importance of auditory providers from different professional back- access, and a keen awareness of the linguis- grounds provide comprehensive educational tic challenges and hazards that face students services by working with individuals and their who are D/HH, SLPs who are knowledgeable, families, caregivers, and communities to de- skilled, and inquisitive can and do support liver the highest quality of intervention across the established trajectory of learning of these settings. The tenets of IPP would suggest that students. each team member has a designated contribution to make with regard to the needs of Building the team students who are D/HH and might also be Interprofessional teams are formed and re- ELs. This means that attitudes of professional formed depending on the abilities and needs centrism are discouraged to avoid scenarios in of the individual students for whom they are which one team member assumes greater im- assembled. It might be suggested, then, that portance than the others (Pecukonis, Doyle, the makeup of any particular interprofessional & Bliss, 2008). Interprofessional practice calls team is driven by the specific profile of the stu- for a more conscious and focused effort as dent who is D/HH. Students presenting with a a team member in which each individual is Keep Up profile might need a small team, for responsible for bringing integrity, commit- example, an audiologist, a classroom teacher, ment, engagement, and effort to the team. and an SLP (bilingual or monolingual if thresh- Blaiser and Nevins (2017) acknowledged the olds for qualifications for services are met). In self-work that is needed to become a con- some cases, however, even a student with age- tributing team member and offered practical appropriate language and literacy skills might suggestions for the IPP team members who need a team with additional personnel, such work with students who are D/HH. They cau- as an itinerant teacher of students who are tioned against waiting for scheduled IEP meet- D/HH, a captioner, a notetaker, or perhaps ings to be the impetus for communicating,

suggesting that these formal meeting were es- sense for all involved, especially the student sentially insensitive to a need for discussions who is D/HH. regarding hearing fluctuation or variable lan- That said, families who might not have had guage performance as a function of various access to practitioners who speak their pre- listening environments at school (classroom, ferred language face an additional challenge cafeteria, gymnasium, therapy room). They of understanding the information supporting urged the use of both formal and infor- early LSL development of their child in or- mal communication strategies (e.g., check- der to enhance their knowledge and skills. lists, forms, e-mail, or notebooks) to keep Cultural differences that are not understood team members apprised of student progress. by practitioners may pose an additional bar- Unique situations may also call for a recast of rier. If this has been the case, it would not more traditional team members. be surprising to discover idiosyncratic gaps in Consider the following scenario of a middle families’ understanding of hearing loss, its ef- school student, Estuardo, who is on a Keep Up fect on language learning, and familiarity and trajectory: comfort with the strategies and techniques for LSL development. Furthermore, if congenital Estuardo is a bilateral hearing aid user whose hearing loss is not identified until after the parents are migrant workers and speak Kekchi early intervention years, there will be a loss at home. In elementary school, Estuardo demonstrated the profile of a Keep Up learner. Now in of not only critical learning time for the child middle school, he is struggling with wear time of but also dedicated time for family learning. his devices and social acceptance in his classroom. As a factor in long-term outcomes, effects of Issues of school avoidance are beginning to appear missing the early intervention period are com- and general withdrawal behaviors are becoming an pounded over the years and influence achieve- increasing concern. No one member of his current ment of a personal best that might never be team is capable of addressing the multiplicity of realized with a different timeline. his needs. Inviting a school counselor, school psy- When appropriately enacted, family- chologist, or an EL teacher to join the team and centered intervention engages the adult collaborate to identify child- and family-focused so- family members and facilitates and coaches lutions seem to be the most direct path to redirect their development of the knowledge and him to his previously promising learning trajectory. skills that foster language learning for their child. All too often, once the child begins to Principle 5: Families are included and attend school, the focus shifts to teachers empowered to be partners in listening, taking on the responsibility of teaching spoken language, and literacy and providing intervention, with families development functioning on the periphery and making Given the fact that Universal Newborn sure that the student completes his or her Hearing Screening makes it possible to screen homework. Studies that have examined the for hearing loss in children, identification of contribution of family involvement in the hearing loss in the first few weeks and months preschool and school years for students of life has become imminently achievable. In who are D/HH have concluded that it is a turn, early identification opens the door for strong predictor of language proficiency and families to play an integral role in their child’s academic achievement (Boons et al., 2012; LSL development. Families are nurtured in fo- Reed, Antia, & Kreimeyer, 2008). cused intervention in which they play a promi- nent role and develop a disposition to inclu- Role of family sion and active participation as their child’s Many families of students who are D/HH first teachers. To continue this early relation- have been coached during the early in- ship with families through the preschool, el- tervention years to create a language-rich ementary, and high school years makes good environment and engage in meaningful

interactions with their child. In that period, Up students still keeping up? Is college or uni- efforts are focused on establishing consis- versity attendance on the horizon? If so, what tent use of hearing technology, acquiring first is the transition plan to make that goal a re- words and sentences, and enjoying shared ality? How can families assist their student to book reading. Families require similar support continue to reach personal best? Other types and coaching if students begin to question the of postsecondary education might be consid- value of their hearing technology or struggle ered for the Catch Up student, who despite with mastery of higher level auditory skills, his or her best efforts still struggles with the Tier 2 and academic vocabulary, increasingly rigors of an academic track. With socially com- complex syntax, or challenging reading and petent linguistic skills, there are many options subject matter assignments. When families for postsecondary endeavors for the students understand the strategies that practitioners who demonstrate this profile of potential and are using, they can support the child’s learn- families may need support as they make ap- ing beyond the classroom environment and propriate adjustments to their previous de- into real-world experiential learning. Talking sired outcomes for their child. For families of aloud about nuances in conversations, ex- students who continue to progress on a Move plaining social conventions, and the linguis- Up trajectory in their later years of school- tic choices that are made in exchanges in the ing, realistic, potentially difficult choices may larger community can be quite instructional. need to be made to prepare the student This explicit instruction provided by the fam- for adult life. Success for students in the ily can build confidence in conversation initia- later years of their educational journey be- tion and participation within the community. comes increasingly idiosyncratically defined. When the language of instruction in school Practitioners who work with these students is provided only in English or mostly in En- (and their families) must be sensitive to the glish, the responsibility for the development emotional ramifications of reaching the end of increasing sophistication in the home or of the traditional K-12 period and be prepared heritage language becomes the purview of to have frank conversations that will drive the family. Because culture and heritage lan- IEP/transition plans. guage are inextricably linked, families can be Finally, families who have long advocated encouraged to develop advanced home lan- for their children who are D/HH to get guage capacity that will allow their student needed services and supports may find it who is D/HH to appreciate stories associated difficult to relinquish this important role to with familial and cultural heritage and to be a their children. But the long-term benefits for full participant in family life. Especially impor- building self-advocacy dictates that it must tant are the language and vocabulary that iden- become part of the IEP for students who are tify and describe the kinship relationships the D/HH. With self-advocacy as an explicitly students have beyond the nuclear family. As stated IEP goal, students can develop the a counterpart to advancing English language confidence, as well as the language, to skills, understanding of and appreciation for advocate for themselves. Nevins and Chute idiomatic expressions that have meaning in (2018) have suggested that students must be the context of the home language can support able to make requests that help getting their participation in communicative exchanges at access needs met. For example, one request home. might be for other students in the classroom As students move through the elementary to pass around a microphone that transmits years, families also may choose to revisit goals directly to the student’s hearing device during they set while their child was still in the early discussions so that the student who is D/HH phase of intervention and reconsider whether has an opportunity to hear every student’s those goals continue to be applicable/ contribution firsthand. Asking a teacher reachable as the student ages. Are the Keep to repeat a question, a spelling word, or

homework assignment may be necessary such as those presented in this article (in- more than once per day; knowing how cluding the Supplemental Digital Content A, to pose these requests in a manner the available at: http://links.lww.com/TLD/A59) teacher can accept is an important ancillary and associated articles in this issue of Top- to the academic curriculum and successful ics in Language Disorders are offered to participation in the mainstream classroom. practitioners to guide intervention and sus- Self-advocacy statements that are commu- tain advances made in a child’s early language nicated in a clear and nonconfrontational journey. manner can have greater pragmatic accep- As indicated previously, outcomes of stu- tance than a first salvo that is demanding dents who are D/HH or D/HH and EL are or complaining. Command of the language, influenced by a number of extrinsic factors vocabulary, and social signals required to be over which there is a degree of control. En- clear in communicating advocacy needs is suring quality service provision to address the crucial and may be included as important highest priority needs of these students is intervention goals for any student who is well within the reach of teachers and SLPs D/HH. For more information about resources committed to mindful practice. These prin- for self-advocacy development, see Sup- ciples and practices are based on the cur- plemental Digital Content A (available at: rent state of knowledge in the field. We ex- http://links.lww.com/TLD/A59). pect that advances in hearing technology, early intervention, and new findings from lan- CONCLUSIONS guage and brain research, especially those related to bilingual acquisition, will lead to The five principles of LSL intervention that an expanded set of principles and practices are presented in this article are meant to in- in the near future. We urge practitioners to form the practitioner in the development of stay fully engaged in the field and expand listening, language, and literacy skills in a their knowledge related to the development systematic manner that meets the individual of LSL. Through ongoing professional learn- needs of each student who is D/HH or D/HH ing, practitioners can continue to refine the and EL. An interprofessional team working in skills needed to assist students who are D/HH collaboration with the families can help stu- or D/HH and EL in keeping up, catching up, or dents achieve their personal best. Resources moving up.

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