Thesis by Chula Seneviratne

M.A.THESIS IN LINGUISTICS

FIRST LANGUAGE ACQUISITION IN HEARING IMPAIRED CHILDREN WITH COCHLEAR IMPLANT

L.C.SENEVIRATNE Department of Linguistics University of Kelaniya 2011 FGS/MA/LING/09/116

Contact;

Chula Seneviratne

seneviratne29@hotmail.com

DECLARATION Declaration by the candidate. I hereby declare that the work embodied in the thesis was carried out by me in the Department of Linguistics. It contains no material previously published or written by another person. It has not been submitted for any degree in this university or any other institution.

Name:

L.C.Seneviratne.

Signature :...................................

Date: 31st January 2012

(Candidate)

Certification of the above statements by the supervisor. I hereby certify that I have supervised this dissertation.

Name: Professor G.J.S. Wijesekara.

Signature:..............................................

Date: 31st January 2012

(Supervisor)

ABSTRACT This thesis talks about the language acquisition of hearing impaired children with cochlear implant. Once they receive the CI only, these children gain the ability to perceive language and then only they will be led to produce words after different stages of L1 (first language) acquisition process. This is mainly because until then they are not being exposed to auditory input. Therefore, this thesis basically deals with the contributory factors towards making L1 acquisition successful within CI (cochlear implanted) children. These contributory factors are age at implant, parental support and the degree of rehabilitation. Consequently, it was also investigated how these CI children acquire their first language (Sinhala language) and the developmental stages in accordance with English language acquisition process. This once again pays attention to find out the significances of language components with related to Sinhala language in their production. Nevertheless, this thesis stresses on the appropriate language rehabilitation methods which would suit different ages basically, the cochlear age (implant age) which means after CI children receive auditory input. Various methods were used in collecting data in order to prove the topic of this

thesis.

Therefore,

focus

group

discussions,

telephone

conversations,

questionnaires, direct observation, interviews were used in the process of collecting data. Overall, it was quite evident that one could easily reach the final conclusions of this thesis without any doubt due to the accurateness of these data collecting methods. Still there could be differences in the levels and ways of L1 acquisition of CI children since this is not unique to all. Therefore, it was identified that all the above factors contribute a lot towards making these CI children learn their mother tongue in every aspect of language such as phonologically, morphologically, syntactically etc. Nevertheless, it is expected to eradicate the misconception that, a HI child could easily acquire L1 merely with a CI, because ultimately it was proven that all the above mentioned factors are equally important towards making L1 acquisition effective.

ACKNOWLEDGEMENTS I make this opportunity to thank all those who helped me in numerous ways to make this thesis a great success and it‘s a pleasure to thank all of them. Initially, I will forever be indebted to two fabulous people for their direct and constant support provided throughout this thesis. Without them I‘m sure I would never have been able to do this. They are my supervisor and my husband. My supervisor Professor G.J.S. Wijesekara

played many roles being a

mentor, encourager, comforter and supporter at several instances. Whenever I was in need of her help she always came up with a smile to help me irrespective of all her other busy schedules. Your gentle encouragement and proposals of creative options took me a long way in the course of this study. Nevertheless, I am really grateful to you for giving guidance through your encyclopedic practice of linguistics which really inspired me. Next, I want to thank my dearest husband Jagath Seneviratne sincerely and warmly, who rendered continuous support at every level. Your encouragement, affirmation and advice were immediately responsible for this achievement. Your endless faith in me and commitment to raise me up through what you knew I could do (even when I didn‘t) is the direct catalyst for me. Everyone dreams to have a husband like you but I‘m very lucky to have you. In the same way, I would like to give a big thank you to my two darling daughters Dinuki and Malki for their forbearance in my absence whenever I was busy with this research. Furthermore, there are so many other people who helped me in collecting data and they all receive my heartiest gratitude. Among them Dr. A.D.K.S.N. Yasawardana , E.N.T. surgeon and Mrs. Thamara Perera, nursing officer are paid due respect and gratitude at this moment for supplying me with data. The immense knowledge of cochlear implant which I gained from Wickramarachchi Institute of Speech and Hearing was mainly due to the helping hand of its proprietor Mr. M. Wickramarachchi and to the professional collaboration of the rest of the staff. Among them

Mrs. Preethi Peiris, my beloved friend, you

have become one of the strongest pillars behind this research, as you did not have a iii

second thought at any time in helping me. Thank you so much for being characteristically generous. Moreover, my heartfelt gratitude goes to Mrs. Hema Fernando, a teacher, a speech therapist for giving me every possible opportunity to investigate the L1 acquisition in CI children who came to her for rehabilitation programmes. Dear parents, you have been so supportive to me by revealing all the necessary facts which helped a lot in doing this research. Thank you so much for your immense support. Last but not least, I would thank my dear CI children who have been with me for several months giving me the fullest support to make this task a success. If not for you all my dear children I will never have this prestigious opportunity. Once again, I owe my deepest gratitude to all the above individuals and all the other people whose names are not mentioned but have assisted me one way or another.

CONTENT DECLARATION .......................................................................................................... i ABSTRACT ................................................................................................................. ii ACKNOWLEDGEMENTS ........................................................................................ iii List of Tables............................................................................................................. viii List of Figures ............................................................................................................. ix List of Abbreviations.................................................................................................... x CHAPTER ONE .......................................................................................................... 1 1.0 Introduction ........................................................................................................ 1 1.1 Classification of Hearing Impairment ................................................................ 1 1.1.1 Measuring Hearing Loss ............................................................................. 2 1.1.2 The Aim of this Thesis ................................................................................ 3 1.1.3 History of Hearing Aids .............................................................................. 4 1.1.4 History of Cochlear ..................................................................................... 4 1.2 Objectives ........................................................................................................... 5 1.2.1 Parental Support ........................................................................................ 5 1.2.2 Age at implant ............................................................................................. 6 1.2.3 Language Development .............................................................................. 7 1 .2.4 Rehabilitation Process and Strategies ........................................................ 7 1.3 Research Problem............................................................................................... 8 1.4 Research Hypothesis .......................................................................................... 9 1.5 Research Methodology....................................................................................... 9 1.6 Significance of the Research ............................................................................ 10 CHAPTER TWO ...................................................................................................... 12 2.0 Introduction ...................................................................................................... 12 2.1. Way we hear .................................................................................................... 12 2.1.1 The sections of the ear............................................................................... 12 2.2. Hearing Impairment .................................................................................... 14 2.3. Cochlear Implant ............................................................................................. 18 2.3.1 What is a Cochlear Implant and how it works .......................................... 19 2.4. The CI surgery................................................................................................. 22 2.4.1. Pre operative evaluation of a CI ............................................................... 22 2.5. Factors which influence the efficacy of L1 acquisition in CI children ........... 25 2.6. Conclusion ...................................................................................................... 26 v

CHAPTER THREE.................................................................................................... 27 3.0. Introduction ..................................................................................................... 27 3.1. Parental Support .............................................................................................. 27 3.1.1. Responsibilities of these parents at different levels ................................. 29 3.1.2. Parental Support Towards L1 Acquisition ............................................... 32 3.3 –Rehabilitation Process .................................................................................... 38 3.3.1. Developing listening skills in CI children. ............................................... 39 3.3.2. Developing Speaking Skills ..................................................................... 49 3.3.3. Some Activities used in Rehabilitation Programmes ................................... 51 3.3.4..Mainstream Education ................................................................................. 57 3.4. Conclusion ...................................................................................................... 58 CHAPTER FOUR ...................................................................................................... 59 LANGUAGE DEVELOPMENT IN CI CHILDREN................................................ 59 4.0 Introduction ...................................................................................................... 59 4.1 Introduction to Language Development ...................................................... 59 4.1.1- Language Development and Age at Implant ........................................... 62 4.3. Language Development and Rehabilitation ................................................ 80 4.4. Language Development and Parental Support ............................................ 82 4.5. Social – Emotional Development of a CI child .............................................. 83 4.6. Analysis of Language Acquisition in CI children. .......................................... 84 4.6.1. Auditory – Verbal Analysis ..................................................................... 85 4.6.2.2.1. Phonological Development. .............................................................. 96 4.6.2.2.2.- Lexical Development. ....................................................................... 98 4.6.2.2.3. Morphological Development .......................................................... 102 4.6.2.2.4. Syntactic Development. ................................................................... 104 4.7. Conclusion .................................................................................................... 105 CHAPTER 5 ............................................................................................................ 106 GENERAL CONCLUSION .................................................................................... 106 5.0- Introduction ................................................................................................... 106 5.1. About Cochlear Implant ................................................................................ 107 5.2. Summary of Main Findings .......................................................................... 107 5.2.1. Age Factor .............................................................................................. 107 5.2.2. Parental Support ..................................................................................... 110 5.2.3. Rehabilitation Process ............................................................................ 110 5.2.4. Language Development ......................................................................... 111 5.3 Future Research Problems ............................................................................. 114 APPENDIX 1 ........................................................................................................... 116 vi

APPENDIX 2 ........................................................................................................... 117 APPENDIX 3 ........................................................................................................... 123 BIBLIOGRAPHY .................................................................................................... 124

vii

List of Tables Table 2.1 - Hearing Process

Table 3.1 - Cochelear Implant Listening Skills Development

Table 3.2 - Check Table

Table 4.1 - Sounds of Speech

Table 4.2 - Stages of Language Development In Children

viii

List of Figures Figure 2.1 - Levels of hearing loss

Figure 2.2 - OAE Report

Figure 3.1 - Model of the aided audiogram

Figure 3.2 - Ling-6 Sounds and their frequency levels

Figure 4.1 - Audiograms

List of Abbreviations CI

Cochlear implant

CI children

Cochlear implanted children

Hearing impaired

First language (Throughout this thesis L1 of these CI children is considered as Sinhala language)

CHAPTER ONE

GENERAL INTRODUCTION 1.0 Introduction This chapter will basically give a brief introduction about this whole research which is based on language acquisition in hearing impaired children with cochlear implant (CI). Furthermore, this will also discuss about age at implant, parental support and rehabilitation as the main factors which contribute towards the efficacy of a CI.

1.1 Classification of Hearing Impairment

Hearing impairment is a disability which could be diagnosed at several instances. It could be identified prelingually as well as post lingually. Pre lingual hearing impairment means a child becoming deprived of auditory input before acquiring the language and post lingual hearing impairment means a person or a child becoming deprived of auditory input after acquiring the language. When we talk about the pre lingual hearing impairment it could be once again classified in different ways. One instance of becoming pre lingually hearing impaired is basically due to heredity. Apart from that, other external factors like disorders within the childâ&#x20AC;&#x2DC;s auditory system could cause this impairment or it could be either due to complications during the pregnancy period. Anyway the symptoms for this kind of pre lingual deafness would be the same in an infant irrespective of the cause of getting pre lingually hearing impaired. Post lingual hearing impairment occurs basically due to some illness after a child acquiring his or her mother tongue. Although here we stress on children, it does not mean that the adults are safe enough to be away from becoming hearing impaired due to several illnesses. Meningitis is a very famous ailment which causes this post lingual hearing impairment.

1.1.1 Measuring Hearing Loss

This hearing impairment is measured basically in decibels hearing level (dBHL) which will be carried by a hearing health professional. The hearing test shown on a chart is called an audiogram. The amount of hearing loss is ranked as mild, moderate, severe or profound.

They are as; 

Normal hearing

Hear quiet sounds down to 20 dBHL



Mid hearing loss

Hearing loss in the better ear between 25-39 dBHL Have difficulty following speech in noisy situations.



Moderate hearing loss

Hearing loss in the better ear between 40- 69 dBHL Have difficulty following speech without a hearing aid.



Severe hearing loss

Hearing loss in the better ear between 70-89 dBHL Require powerful hearing aids or an implant.



Profound hearing loss

Hearing loss in the better ear from 90 dBHL Need to rely mainly on lip- reading and sign language or an implant.1

In order to overcome this impairment conventional hearing aids were used all these years till the cochlear implant was being introduced to the world. After this intervention almost all the people especially the parents of hearing impaired children were very much enthusiastic of getting down the device to their children irrespective of its high cost.

www.cochlear.au.com

1.1.2 The Aim of this Thesis

This thesis mainly talks about the efficacy of Cochlear Implantation with regard to language acquisition of hearing impaired (HI) Cochlear Implanted (CI) children. This also deals with other supportive factors which contribute a lot towards language acquisition of hearing impaired CI children, apart from the surgery. This research would be helpful in making hearing impaired CI children to grow up in a normal learning and living environment by fulfilling the other supportive factors which would increase the efficacy of the CI in the process of their first language acquisition. Although there are many supportive factors which should be fulfilled in order to get the maximum benefits of a CI. This research concentrates on the effects of the parental support, age at implantation and the rehabilitation process after the surgery. All these three areas are being considered as compulsory factors with regard to the efficacy of language acquisition of CI children. Nevertheless, the language development of these CI children is also taken in to consideration. Not only that but most of the literature reviews argue that the government too should he more supportive in the course of supplying the CI device due to its high cost which is being undertaken by the private sector. If the government could make necessary arrangements to import these devices, people could be benefited. This dissertation could be one of the early pieces of writing with relevance to acquisition of Sinhala language in CI children, although there are so many studies which are being handled with regard to acquisition of other languages as L1 in CI children. Therefore, this topic covers a wide area although this particular thesis aims at handling L1 (Sinhala language) acquisition of CI children within the Sri Lankan context. Nevertheless, it should be emphasized that this study contains the significant facts about language development of CI children who belong to 2-6 years of age. Similarly, this will deal with the early development of L1 from the beginning of receiving a CI, as it is assumed that this age limit will contribute a lot towards making L1 acquisition effective than any other age limit with regard to all the aspects of language like clarity, stress, intonation patterns etc. which would once again help these CI children live in the society as normal children. The situation of hearing impaired children in the society is very pathetic due to loneliness and depression which arise as a result of isolation. The main reason for this is the inability of hearing impaired children to communicate with their friends 3

and loved ones and mainly due to the fact that they do not have the ability to accept their own disability. As a result to support these hearing impaired individuals the conventional hearing aids were invented.

1.1.3 History of Hearing Aids

Conventional hearing aids invented by Alessandro Volta in 1800, stimulated hearing in hearing impaired individuals, with an electrical current by connecting batteries to two metal rods, which later on were inserted into the ear. Volta described the sensation of it was similar to that of boiling thick soup which was rather uncomfortable. Some 157 years later, the battery supplied electrical current was first used to stimulate the auditory nerve in deafness. In the 1960 s and 70 s, great advances were made in the clinical applications of the electrical stimulation of the auditory nerve. This resulted in a device with multiple electrodes driven by an implantable receiver and speech processor, the Cochlear Implant. Due to the technological advances of the CI the efficacy of speech perception is emphasized irrespective of the age limit.1

1.1.4 History of Cochlear

1982

–

First commercially available 22 channel implant

1985

–

First to gain regulatory approval for adults

1990

–

First to gain regulatory approval for children

1993

–

First Auditory Brainstem implant

1994

–

SPEAK speech coding strategy introduced

1996

–

First implant to offer 10 year warranty

1997

–

Nucleus® 24M implant released

1998

–

10,000 children with a Nucleus® implant First multi channel BTE speech processor

http://en.wikipedia.org/wiki/Cochlear_implant 4

ACE™ speech coding strategy introduced 1999

–

Only cochlear implant approved for infants at 12 months Contour™ Electrode introduced

2001

–

Over 36,000 adults and children now implanted BTE introduced for Nucleus® 22 recipients

2002

–

Our 3rd generation BTE, ESPrit™ 3G introduced ADRO introduced to the SPrint™ body worn speech processor

2004

–

ESPrit™ 3G for Nucleus® 22 released

1.2 Objectives Before the advent of CI, most individuals of hearing impairments managed to maintain their auditory perception through conventional hearing aids irrespective of the shortcomings which those hearing aids had. Although sound clarity and intelligibility are attainable through hearing aids, they do not supply comfortable listening. Due to these factors CI receives greater social acceptance. Although CI was invented for the first time in 1982 it did not become very popular those days. But from the year 2004 onwards it gained much popularity and in 2005 the first cochlear implant took place in Sri Lanka. From that point onwards people tend to use it due to many recommendations of the doctors. Although there was a huge trend towards CI worldwide, it is much less in Sri Lanka in comparison to other countries, may be due to the high cost of the device. But still one could find a fairly considerable amount of children who have undergone this CI surgery in Sri Lanka.

1.2.1 Parental Support

Main objective of this study includes many areas connected to CI, such as how well children with CI acquire their first language and about other supportive factors which go hand in hand with the CI, to get the maximum benefits out of the CI and to enable those children to intrude into mainstream education. Thereby this

research intends to compare the level of language production and acquisition with and without much of parental support. Nevertheless, this research would once again find out the effectiveness of first language acquisition against factors like, spoken skills of parents, integration of the family rehabilitation programmes conducted by speech therapists and supported by parents.

1.2.2 Age at implant

Apart from the parental support which would help to get the maximum benefit of a CI in the process of language acquisition, this study would also deal with the findings of the most suitable age at which the CI should take place. This perspective of the CI would again support the fact that how well it would affect the process of L1 acquisition in CI children. Moreover, this would also pay attention towards the cause and age of becoming hearing impaired with connection to L1 acquisition process of CI children. This intends to find out how a child who has been normal in his hearing reacts after becoming hearing impaired due to several diseases like meningitis. Here it is debated whether a child who had proper hearing ability for some time would also become similar in hearing impairment as a normal hearing impaired child by birth. For these children, the efficacy of the CI in the development of oral language has shown systematic improvement although they had had a proper hearing ability before. The more they lack exposure to hearing sounds, the more they forget the language they were used to. Therefore, they too tend to show more or less the same characteristics of a hearing impaired by birth. However, further analysis of the language data reveals that the development of L1 acquisition is not uniform across language domains as well as in different children .This statement once again supports this thesis topic as this too brings evidence to show that many more facts are responsible in developing the efficacy in L1 acquisition in a hearing impaired CI child irrespective of any other external factors like age or cause of becoming hearing impaired.

1.2.3 Language Development

With accordance to all the above factors, these CI children were observed simultaneously to find out their developmental stages in acquiring L1. Acquisition of language within these CI children was identified under several perspectives such as phonologically, morphologically and syntactically. Moreover, it was tested under audition, language, speech, cognition and communication too. Nevertheless, L1 acquisition of these CI children was investigated with comparison to language developmental stages of a normal hearing child as it is more or less the same within the CI children after the proper auditory input, except in post lingual hearing impaired.1 Since most of the standard findings about language acquisition is related to English language, those specifications were taken into consideration and were compared with the acquisition of Sinhala language elements and investigated about similarities and differences between those two languages.

1 .2.4 Rehabilitation Process and Strategies

Another factor which is equally important in making a CI effective in the process of language acquisition is rehabilitation. This is mainly taken in to consideration in this thesis as most parents have the misconception that the CI surgery itself would totally benefit their children in acquiring their language. Therefore, most of the parents do not pay much attention to send their HI children to speech therapists. Although it is intended to talk about the above facts separately, all these factors have equal importance in the field of making a CI surgery effective towards language acquisition. Therefore, the main objective of the present study is to lay a better concept as to how a hearing impaired child would be benefited with a CI in isolation and how effective it would be in providing sufficient access to auditory speech input in acquiring language. This would also be an eye opener to the caregivers, therapists and parents of CI children as to how and what factors should be taken into consideration in order to get the maximum benefits out of a CI. 1

http://www.cochlear.com/files/assets/Listen-Learn-and-Talk.pdf

Nevertheless, this would provide some kind of an idea as to how these CI children grasp and develop L1 through different stages of acquisition.

1.3 Research Problem The area of this research deals with the possibility of developing oral language in hearing impaired CI children. Since the language acquisition process of these children are not uniform ,this is meant to find out the causes for it and at the same time the possible measures one could take in order to develop this. Thereby, this piece of writing would deal with the external factors which contribute towards the efficacy of language acquisition, production and perception of a CI child. Firstly, it is argued whether the CI surgery in isolation would he sufficient for a hearing impaired child to possess normal hearing and if not what other factors should be given prominence such as the age at implantation, the cause for being hearing impaired, parental support and the rehabilitation programme. Above all, the developmental process of language acquisition within these CI children also has been taken into consideration. This would help in finding the different stages of language acquisition of a hearing impaired CI child. Most of the literature reviews believe on the efficacy of the Cochlear Implant according to the age of the surgery; thereby, most of the medical officers say that the earlier a child under goes a CI, the easier that child acquires the oral language. Therefore, the sample data will prove the most appropriate age limit which would enhance to gain the maximum benefits from a CI. Nevertheless, the teaching methodology , its specifications will also be taken into consideration At the same time the practicality of handling children with CI, the steps to be followed in rehabilitation starting from auditory-visually which would later on can he presented auditory alone.

1.4 Research Hypothesis Although this study is divided into several areas like how parental support, age at implant and rehabilitation process affect in developing L1 acquisition within CI children, it was clearly identified that all these factors are equally important simultaneously in order to get the maximum efficacy of a CI. Thus, HI children will never achieve a good level of language proficiency if not for the collective effort of all the above factors. Nevertheless, it was quite evident that the children, who receive a CI early in life, are better in L1 acquisition than who receive it later.

1.5 Research Methodology The sample data which is used in this research is mainly children below 8 years. These children once again could be categorized under several perspectives. According to the objectives in this research the sample data is divided as the age of becoming hearing impaired, whether by birth or later due to some other external or internal factors. Apart from that the cause of becoming hearing impaired is also taken into consideration and thereby how their levels of language acquisition vary. Another perspective of categorizing these children is with reference to the age at CI which would be more helpful in drawing conclusion in language acquisition of CI children. The sample data was again categorized according to the level of parental support and how effective the CI children acquire their first language along with that. Nevertheless, when it comes to parental support the rehabilitation process of the therapists also was assessed as to what factors and methods should be taken into consideration when it comes to uplifting language acquisition, production and perception process of a CI child. Therefore, the research methodology of this thesis deals with the education, economy and psychological status of parents and the teaching methods followed in rehabilitation process. These were observed in order to figure out the efficacy of language acquisition of CI children. Particularly, almost all the data was gained through the methods of observation, questionnaires, interviews and focus group discussions. Focus group discussions were very much helpful in

drawing conclusions as they demonstrated great assurance in their authentic experience which really matched with the findings too. The age group of this research varied from 2 years to 6 years which included children with hearing impairment by birth as well as due to other ailments like meningitis. Some of these children had been once exposed to the normal life but they later on got this hearing impairment as a side effect of meningitis. But they even later on showed impairments in auditory input. They show more or less the same deficiencies as a child of hearing impaired by birth, even they knew a set of vocabulary earlier and led a normal life. Moreover, the tendency of forgetting the so called earlier used vocabulary grows higher with the hearing loss since the auditory nerve doesnâ&#x20AC;&#x2DC;t stimulate as a normal child. The sample was once again observed under a teaching / rehabilitation environment at the very beginning since they were unable to produce language spontaneously at the early stage of CI. Therefore, the L1 production of these CI children was investigated step by step with the help of stimuli. Nevertheless, other methods like questionnaires and focus group discussions were very much helpful in drawing conclusions.

1.6 Significance of the Research Significance of this research mainly lies on the focus of the acquisition of L1 in hearing impaired children with cochlear implant. Moreover, this deals with the efficacy of it in relation to parental support and rehabilitation as well as the age at implantation. Language acquisition of these children is being taken into consideration with relevant to the cause and age of hearing impairment and at the same time it is also considered whether the age at implant creates any impact on the progress of L1 acquisition in CI, hearing impaired children. Although this is a fact which should get social consideration and mainly the governmental consideration due to the high cost of the CI device, it is not being fulfilled yet. Due to the psychological impact in HI children as well as their families,

adequate measures should be taken in order to eradicate the psychological stress which this group of people under goes. This would also be a timely and useful study as most parents of CI children struggle a lot in establishing proper auditory speech input within their children after the surgery. Nevertheless, this will give proper guidance as to how people in the society should act with relevance to hearing impaired children as they undergo severe mental trauma due to their inability to stand on their own in the normal society.

1.7. Conclusion As the conclusion of this chapter, it could be stated that the rest of the thesis will deal with all the above factors which come under objectives by using the specified methodology. It can be also emphasized that through the findings of this research it was easy to figure out the hypothesis clearly.

CHAPTER TWO

COCHLEAR IMPLANT 2.0 Introduction This chapter focuses on giving a brief description on the process of hearing, the sections of an ear, hearing impairment, classification of hearing impairment, categorization of ages at onset as in pre-lingual deafness and post-lingual deafness, about the CI as a device and how it works in the field of supplying auditory perception. The advent of hearing loss should be initially done by the parents, as that affects the efficacy in every other way of a CI operation. Therefore, this chapter would be very helpful in knowing about hearing impairment and the symptoms of it in order to take necessary steps to eradicate the defects caused due to hearing impairment.

2.1. Way we hear The following details bring out a brief description about the parts of the ear and how it works. Nevertheless, this will give a clear idea as to what disabilities make a person hearing impaired.

2.1.1 The sections of the ear

There are three major parts to the ear and they are outer ear, middle ear and inner ear which is called as the cochlea. These different parts work in different ways in helping a person to have proper auditory input.

Outer ear

catches the sound waves and directs them into the middle ear.

Middle ear

transfers sound waves in air into mechanical pressure waves that are then transferred to the fluids of the inner ear.

Inner ear (cochlea) -

turns pressure waves into sound signals that our brain can understand.1

See ď ľ Appendix 3 (Video Clip No. 1)

2.1.2. Hearing Process

Picture 2.1 - Hearing Process

( http://www.cochlear.com/au/hearing-and-hearing-loss/how-hearing-works-children)

Table : 2.1 Hearing Process 1

Sounds enter the ear canal

The ear drum and bones of

Sound waves move through the

hearing

ear

These sound waves cause the

canal

and

strike

the

eardrum.

vibrate

eardrum, and the three bones (ossicles) within the middle ear, to vibrate.

Fluid

moves

through

inner

the 4

Hearing nerves talk to the

ear

brain

The vibrations move through

The hearing nerve then sends

the fluid in the spiral shaped

the information to the brain

inner ear – known as the

with electrical impulses, where

cochlea – and cause the tiny

they are interpreted as sound.1

hair cells in the cochlea to move. The hair cells detect the movement and change it into the chemical signals for the hearing nerve.

See  Appendix 3 (Hearing Process) (Video Clip No. 2)

2.2. Hearing Impairment

Hearing impairment is a condition which makes an individual completely or partially impaired in detecting certain frequencies of sound. There are different types of hearing losses. They can be categorized as conductive hearing losses and sensorineural hearing losses. Mainly sensorinueral hearing loss can be treated 1

( http://www.cochlear.com/au/hearing-and-hearing-loss/how-hearing-works-children)

through CI. This type of hearing loss occurs mainly due to the problems in the cochlea in the inner ear, or along the auditory nerve which leads to the auditory areas in the temporal lobe of the brain. Heredity and diseases like meningitis are mainly regarded as common causes for this type of hearing loss.1 Many people suffer from hearing loss because they have damaged hair cells in the inner ear (cochlea). If some hearing nerves still work, a CI can allow that person to hear well.2 Anyway, these various types of hearing impairments should be measured through audiograms before any treatment. Therefore, audiologists and E.N.T. surgeons decide on the appropriate medication for HI children or adults with the help of the results of the audiogram. Here is a sample set of audiograms which reveals different types of hearing impairments: These stages are quite clearly indicated through these audiograms

Figure - 2.1 - Levels of hearing loss This audiogram shows 'normal' hearing. Sounds below the lines on the audiogram can be heard. X shows the left ear. 0 shows the right ear. All the X and 0 are above the 20 line.

This

means

hearing

'normal'.

Range of hearing loss A hearing loss can be mild, moderate, severe or profound This audiogram shows a 'mild' hearing loss. Sounds below the lines on the audiogram can be heard.

Strategies for including children with special needs in early childhood settings : by M. Diane Klein, Ruth E. Cook, Anne Marie Richardson- Gibbs) 2 (http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults)

All the X and 0 are between the 21 and 40 lines. This is a 'mild' loss.

This is a 'moderate' hearing loss. Sounds below the lines on the audiogram can be heard. Low/loud sounds like oo, ah, ay and ee may be heard. All the X and 0 are between 41 and 70. This is a 'moderate' loss. The hearing loss in the left ear is worse than the right ear.

This is a 'severe' hearing loss. Conversational speech cannot be heard. Shouting and loud noise (like traffic) can be heard. All the X and 0 are between 71 and 95. This is a 'severe' loss.

This is a 'profound' hearing loss. 16

Speech cannot be heard. Very loud noises like pneumatic drills and planes taking off can be heard (or felt). The X and 0 are mostly below the 95 line. This is a 'profound' loss. People with very profound hearing losses can feel loud low sounds.

To work out the level of hearing loss 1. Add the Hearing Level (dB) for 250, 500, 1000, 2000 and 4000Hz in the better ear. 2. Divide by 5. 3. If there was no response use 120dB. 1

2.2.1. Pre Lingual HI and Post Lingual HI

Hearing loss could be varied as pre-lingual hearing loss and post-lingual hearing loss whereas pre-lingual hearing loss takes place before a baby starts talking and post-lingual hearing loss takes place in individuals later in life. In this research both types of hearing impairments have been taken into consideration. To diagnose either of the hearing impairments one should be aware of the symptoms and mainly the parents should work closely to the child since it is a silent, hidden disability. This is mainly visible in pre-lingual hearing loss since it is something to do with babies who cannot communicate.

http://www.schooltrain.info/deaf_studies/audiology2/levels.htm

2.2.2. Symptoms of HI

But still if the parents are aware of several age appropriate behaviours of the baby, then they will easily figure out this disability. Likewise, the sample set of parents in this research has observed some of the following symptoms which had been useful to them in order to make early diagnosis of hearing impairments of their children. Among them pre-lingual hearing losses have been diagnosed by some parents due to several behavioral patterns which are not normal. One baby between 0-4 months of age has not awaken for sudden noises during the sleep. Furthermore another parent complained about her baby who did not turn towards sounds that were out of sight at the age of 4 months, which once again has led her to a pediatrician. Nevertheless majority of the parents have diagnosed about their childrenâ&#x20AC;&#x2DC;s disability due to the abnormal babble sound during the age of 6-7 months. Some parents have come across their children producing only the vowel sounds when the same age children are far ahead in producing different sounds. Therefore these symptoms would lead to pre-lingual hearing losses. According to this research it contains pre-lingual as well as post-lingual hearing impaired children. Therefore it was easy to find out the symptoms of postlingual hearing impaired children through their parents.

Most of the post-lingual

hearing impaired children have undergone meningitis and as an after effect of that disease they have been disabled. Thus, those parents complained about several behaviours of their children after meningitis such as frequently asking others to speak more slowly and loudly, turning up the volume of the television or radio, difficulty in understanding words especially against background noise and avoiding social settings or conversation. These abnormal behaviours have led them to medical advice which had later on ended in CI operations.

2.3. Cochlear Implant This part of this chapter talks about the device , cochlear implant, which is going to be the most important part of this whole thesis, because if not for the CI none of these severe to profound hearing loss children will be enabled to acquire language in their life.

2.3.1 What is a Cochlear Implant and how it works

Cochlear Implant is the main issue of this thesis which from now on in this chapter would be dealt with. A CI is a small complex electronic device which is surgically implanted that can help to provide a sense of sound to a person who is profoundly deaf or severely hard of hearing. This is often called as a bionic ear. An implant does not restore or create normal hearing. Instead, under appropriate conditions it can give a deaf person a useful auditory understanding of the environment and help the recipient to understand speech. Thereby it would make the recipient succeed in mainstream educational setting. The basic implant system consists of an implanted electrode array and receiver â&#x20AC;&#x201C; stimulator and an externally worn microphone, transmitter and processor.1 The device is surgically implanted under general anesthetic and the operation usually takes from 1 Â˝ to 5 hours. Firstly a small area of the scalp directly behind the ear is shaved and cleaned. Then a small incision is made in the skin just behind the ear and the surgeon drills into the mastoid bone and the inner ear where the electrode array is inserted into the cochlea. After 1-4 weeks of healing, the implant is turned on or activated. Although it is activated, as most of the parents expect, results are typically not immediate since it needs time for the brain to adapt to hearing new sounds. During this period postimplantation therapy is required with the fullest effort of parent â&#x20AC;&#x201C;professional involvement. When we talk about the CI as a device and its operations it is a very complex process. All cochlear implants have two main components out of which the internal component is implanted as it is mentioned earlier, where as the external component is worn outside. The external component consists of a microphone, an external transmitter and a signal processor or referred as a speech processor. The microphone picks up sound from the environment. The speech processor then selects and arranges sounds picked up by the microphone. The internal component too plays a major role as the external component. Since the internal component consists of electrodes that are implanted into the cochlea, they collect the impulses from the stimulator and send them to the brain. The incoming sound is analyzed by the signal

(Amy Mc Conkey Robbins)

processor and computed into fundamental acoustical information. These represent the key elements of human speech.1

2.3.2. Parts of a CI

Picture 2.2 - Parts of a CI

1. A sound processor worn behind the ear or on the body, captures sound and turns it into digital code. The sound processor has a battery that powers the entire system 2. The sound processor transmits the digitally-coded sound through the coil to the implant 3. The implant converts the digitally-coded sound into electrical impulses and sends them along the electrode array placed in the cochlea (the inner ear) 4. The implant's electrodes stimulate the cochlea's hearing nerve, which then sends the impulses to the brain where they are interpreted as sound.

( (Leading Article Cochlear implants in children Devanand Jha1 Sri Lanka Journal of Child Health, 2005; 34: 75-8)

2.3.2.1. Cochlear implant components

Picture 2.3 : Parts of a Cochlear

Sound Processor

Implant1

See  Appendix 3 (Video Clip No. 3) (Parts of a CI)

2.3.3. The benefits of a cochlear implant

Many adults with cochlear implants report that they: 

Hear better than with a hearing aid Study showed an average 80% sentence understanding, compared with 10% for hearing aids1



Can focus hearing in noisy environments Converse with people across meeting tables, in restaurants and other crowded places



Reconnect with missed sounds The sound of the rain

http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults



Feel safer in the world Hear alarms, people calling out and approaching vehicles and know where they are.



Talk on the phone



Enjoy music

2.3.4. Factors which affect the benefits of a CI 

How long they have had hearing loss



How severe their hearing loss is



The condition of the cochlea (inner ear)



Other medical conditions



Practice using their cochlear implant system1

2.4. The CI surgery Although we talk about the cochlear implant surgery as the basic need to acquire language within these HI children, there are so many other factors which should be completed before the surgery. These steps could be basically categorized as pre operative stage and post operative stage, where pre operative stage pays a great deal of attention to find out the eligibility of the HI child for the surgery and the post operative stage deals with the checking of the auditory level of these HI, CI children and about their rehabilitation programmes.

2.4.1. Pre operative evaluation of a CI

When we consider a CI operation, preoperative evaluation is given much prominence since the progress of the whole surgery depends on this and nevertheless it assures the child‘s health security even after the operation. Therefore, as preoperative

preparation

selection

candidate,

radiological

assessment,

psychological and social consideration is taken into consideration. Moreover plans 1

http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults

for postoperative operations are also being discussed and planned out before the surgery since it too plays a major role in the process of L1 acquisition within a hearing impaired CI child. Therefore, postoperative preparation contains surgical procedure and rehabilitation programming. A surgeon (E.N.T), an audiologist, a speech-language pathologist and a teacher for the deaf are responsible for the candidate selection since it is a multidisciplinary evaluation.

Figure 2.2 - OAE Report

This is a pre operative evaluation of a HI, to check the functions of the cochlea.

2.4.2. Candidacy Selection

There are several factors that determine the degree of success to expect from the operation and the device itself. Therefore candidate selection takes place on individual basis. Thereby a person‘s hearing history, cause of hearing loss, amount of residual hearing, speech recognition ability, health status and family commitment to aural rehabilitation are considered before a CI surgery.1 The selection criteria for inserting a CI in hearing impaired children are as follows, those children should be twelve months of age, however, even before one year of age a child can be implanted when meningitis is the cause for the hearing loss since meningitis causes ossification in cochlea as time passes rendering electrode insertion more difficult. Moreover a child should suffer from bilateral sensorineural hearing loss and at the same time that child is not benefitted from hearing aids. Thus the child should be checked for medical contraindications before the surgery. This brings only a brief set of criteria for candidate selection whereas it is a very complicated matter. Not only the physical perspective of the candidate but also the psychological perspective of the candidate should be examined before the operation. Thereby once again it shouldn‘t only be of the candidate but of the parents and other family members too since they have a vital role to play after the operation which would influence a lot in the efficacy of L1 acquisition.2 See  Appendix 3 (CI surgery – DVD No. 2)

1 2

http://en.wikipedia.org/wiki/Cochlear_implant (Devanand Jha)

2.5. Factors which influence the efficacy of L1 acquisition in CI children There are so many factors which influence speech recognition by children with CI. All these facts are responsible for the efficacy of L1 acquisition in CI children. They are,

Implant technology.

Surviving neural population.

Auditory (sensory) deprivation.

Auditory pathway development.

Plasticity of the auditory system.

Length of deafness.

Age at time of implantation.

Etiology of deafness.

Preoperative selection criteria.

10)

Preoperative hearing level.

11)

Preoperative auditory speech perception.

12)

Measures of speech perception. (preoperative and postoperative)

13)

Preoperative linguistic level.

14)

Other handicaps.

15)

Surgical issues.

16)

Device programming.

17)

Device/equipment malfunctions.

18)

Mode of communication.

19)

Auditory input.

20)

Frequency type of training.

21)

(Pre) school environment /education setting.

22)

Parental/family motivation, social issues.1

Amy Mc Conkey Robbins

Although CI surgery is regarded as only one process on the surface level, it includes several other areas to be fulfilled, which are mentioned above to get the maximum out of a CI in a hearing impaired individual. Still most of the issues mentioned in the above list are beyond the scope of this research, this would deal only three factors which would influence the efficacy of L1 acquisition in hearing impaired CI children such as age at implantation, parental support and rehabilitation programmes.

2.6. Conclusion This chapter dealt with a brief idea of what is meant by hearing impairment, how to figure out this disability in the stages of pre-lingual and post-lingual hearing loss, about the cochlear implant as a device, how it is being inserted, pre and post operation management of a CI etc. Since this describes as to how a parent could figure out the earliest stages of his/her childâ&#x20AC;&#x2DC;s disabilities it would be very much important to get the earliest treatment as possible since it would maximize the efficacy of L1 acquisition of that HI child with proper medical care and nevertheless this child will not be left alone in the society since he/she can educate in the mainstream schools which would once again be a supportive factor in the growth of his/her personality development.

CHAPTER THREE

SUPPORTING FACTORS 3.0. Introduction This chapter deals with some of the supportive factors which would influence the efficacy of L1 acquisition in hearing impaired CI children apart from the medical therapy these children get. Under these supportive factors, the effectiveness of L1 acquisition is measured according to parental support, rehabilitation process and the age at implant. With regard to both parental support and rehabilitation there should be proper sequential order which would be compatible with the implant age of a CI child. Therefore, many audiologists have done several researches and have come to conclusions as to how these CI children should be rehabilitated. This chapter gives an overview of these methods which are being adopted by the therapists in their therapy sessions and how far they have motivated the parents of these CI children to help their children. Simultaneously, almost all the facts show some kind of development with regard to early age at implant. All the developments with CI children who received their CI as early as possible show a speedy development in L1 acquisition, while the other CI children reach that level with much more time consuming. Nevertheless, it should be insisted that most of the researches with regard to CI children language development are handled associating English language, but this thesis has made use of all those theories in such a way which would relate to Sinhala language, as the L1 of the sample set of CI children belongs to that.

3.1. Parental Support Firstly, it is intended to discuss the fact of parental support and how effective a CI child acquires his or her L1 with the help of the parents. This should not only be the parents but it could be the responsibility of other family members and close friends too. This is more important mainly in the field of psychosocial, in the process 27

of socializing HI, CI child. Therefore, although the main aim of this research is to figure out the efficacy of language acquisition in hearing impaired CI children, the behavioural patterns of the parents of these CI children, their economical status, their level of education, their ability in psychological adjustments and their social status were taken into study. Those data were later on analyzed and compared with the L1 acquisition of CI children and thereby

it was easy to draw conclusions as to how

parents with hearing impaired children should act to get the maximum benefits of a CI apart from a successful surgery. Therefore, this would surely be an eye opener to those parents who are really enthusiastic of intruding their HI children into mainstream education. From the beginning of this research the importance of the parental involvement was very significant since they have given their children

proper medical care.

Almost all the parents involved in this research, have taken proper decisions at correct time due to their keen observation irrespective of their social status and the level of education. Nevertheless, although most of the parents in this sample study do not obtain a higher economical state, they have somehow or the other managed to cover the high cost of this CI surgery which in one way seems very pathetic. This situation once again creates great impact on the efficacy of L1 acquisition in HI child although it doesnâ&#x20AC;&#x2DC;t seem directly. Some parents were really honest at moments when they came out with their real emotions which have suppressed them due to the heavy cost of the CI and therefore they rather regret in neglecting their children in the rehabilitation programme. This is mainly due to their inability in positive stress management. Therefore, as postoperative measures of a CI the parents with CI children too should be provided with regular counselling programmes according to their level of education. Although some parents with CI children are highly qualified, they lack the ability to cope up a situation like this throughout their life span since this would ultimately become a real burden handling a CI child in a family. This chapter identifies the stresses of parents with CI children, tied directly to the situation and talks about the psychological adjustments which should be altered within them. This problem should be solved in such a way since it affects the process of L1 acquisition in HI, CI children due to the lack of attention they get from their parents and other family members who have undergone lot of mental trauma. Therefore, mental up liftment programmes for these parents, should be implemented by the

health sector simultaneously with the CI operation in order to make the CI children grasp their L1 more effectively. 3.1.1. Responsibilities of these parents at different levels

When we consider the involvement of parents toward these CI children, it begins from the point at which they diagnose the disability of hearing impairment of their child, which could be categorized as pre-lingual hearing loss and post-lingual hearing loss. The symptoms which led them to recognize their childâ&#x20AC;&#x2DC;s disability were stated in chapter two. Therefore, the necessity of proper parental care is very much evident in every aspect of this cochlear implantation .Thus this chapter focuses on bringing out the importance of proper involvement of parents with CI children to raise the efficacy of language acquisition within their children. The involvement of parents could be observed step by step from the time of diagnosis and giving them proper medical therapy rather than ignoring the disability in order to maintain their social level. Once their children are taken to an E.N.T. surgeon, it is the parents who have to face the crucial stage of finding the high cost needed which they find it with much effort ,being citizens in a third world country like Sri Lanka. Then they have to have proper education in order to understand the advantages as well as the disadvantages of this operation since there are so many irreversible points after an implantation. Therefore the parents should be informed about them and should negotiate with them in order to know whether they are ready to take the risk. Even just after the operation the parents of CI children should be well informed about the steps they should follow with regard to the incision where they have to keep the wound dry for the first few weeks before the implant is activated. They should be well aware of the times they have to shave behind the ear of the CI child in order to fix the speech processor. Nevertheless, the parents should be educated enough to understand the instructions given by the manufacturers of the CI device as they have mentioned so many cautious situations .The parents should pay attention to follow the given instructions in bathing the child, when in sleeping and so on. During these instances the parents should be conscious of turning off and removing the external component of the CI. Nevertheless, those instructions mention about several restricted activities 29

like scuba diving, going near strong magnets etc. Therefore, parents always have to be very vigilant about their children‘s behaviour since they are small. The charging of the battery according to the device is another process which most of the parents find it difficult to follow due to various reasons such as standardized measures of depression, time demands, lack of common sense, illiteracy, anxiety etc. Considering the rehabilitation programmes, it is the parents of these CI children who should come in forward to get the necessary steps to be done to their children. But still most of the parents of these children are in problematic state in finding proper teachers for the deaf. They are in trouble in selecting a teacher or a suitable programme for their children since most of them tend to depend on the information they get from their friends who have got children with the same deficiency. But these parents do not realize that this is a surgery which does not give uniform as well as quick results and therefore they try to compare their CI children with their friends‘ children which is something shouldn‘t be done. Once again it should be the responsibility of the personnel in the medical field to educate the parents with CI children, about the time expansion that will take to get visible improvement in L1 acquisition after the operation. Otherwise it is more natural of them to have high hopes about the recovery of their child‘s disability. When we consider parental support, it was observed that the involvement of mothers was higher to that of fathers in the field of improving L1 acquisition in CI children. Moreover the findings showed the level of expectations of these mothers is somewhat high irrespective of the slow rehabilitation process. Therefore they tend to force the professionals or the teachers for the deaf, regarding the language outcomes of these CI children. It is identified that the cause for these types of behaviours takes place due to their higher level of stress and high expectations. Thus it is thoroughly suggested that the parents of these CI children should be rehabilitated before anything else if the society intends to make the CI children acquire their L1 more effectively. In the matter of handling the CI device it was identified that most of the parents still have not got a proper understanding about its operations, which would definitely influence the efficacy in L1 acquisition of CI children. Although these points are to be considered as minute details, they play a vital role in the efficacy of 30

L1 acquisition since these operations and handling the device properly comes in the basic position. Even most of the well educated set of parents with CI children , said that they still could not follow all the instructions with regard to charging the battery and with regard to handling the device in various manner in different situations. Therefore, to overcome such issues those parents should be given those instructions in their mother tongue or there should be a demonstration as to how they could follow the instructions easily rather than just making profit by selling the product. Or else they could print out the instructions in Sinhala and Tamil too and give them to those parents. Due to the higher level of stress and poor psychological adjustments experienced by the parents of CI children, lack of auditory input takes place which once again poses additional threat to optimal development of a CI child. According to this study it was observed that the whole sample of parents were of normal hearing whereas the children were deaf. Therefore mostly these hearing mothers tend to engage in more controlling, directive actions with their children rather than being more likely to respond to their behaviour. Moreover the available evidence through this research indicates that although a CI child requires some level of effective communication with the parent, it is

not being fulfilled most of the time, mainly

due to the mismatch between the deaf child and the hearing mother. This becomes a significant barrier throughout the life span of them and as a solution for that, these mothers seek the help of some professionals which once again does not become successful since the CI child is not being educated in a stress free environment. Due to their aggressive violent behaviour they are being controlled in such a manner which once again make them inhibited to grasp their L1. Thereby the CI child tends to feel these ill treatments and emotionally upset. Therefore not only the parents but also the caregivers and professionals should be aware of showing them some maternal sensitivity rather than being controlling them all the time although they misbehave. Furthermore it was identified that the parents tend to avoid talking to their CI children as time goes on, since they need much patience and time to tell them everything in a slow manner. These types of negligence mainly take place due to the responsibilities of other normal children in the family. Most of the parents with CI children pay their fullest attention during the first few months of the surgery but after that they fall into a lethargic condition which is something very pathetic from the 31

point of view of the CI children. Therefore this tendency should be eradicated from our society even by increasing the quality of rehabilitation programmes or by training caregivers with full of sensitivity. Otherwise none of us can predict about the future of these CI children positively.

3.1.2. Parental Support Towards L1 Acquisition

Moreover, they have the responsibility to train their children to acquire language too. Therefore, the following tips would be very helpful in teaching their CI children at home. Although this guide is there, some of the parents should be educated by the therapists as well which would appeal according to their level of education. When it comes to parental involvement towards the L1 development in CI children, once again this language developmental process could be initially divided into two sections. Basically, L1 development of these CI children begins with the audition and the input of it should be strengthened. Therefore, these parents should be made well aware of these developmental stages. Likewise, the therapists should assist these parents and should assign them with specific area of sounds that they should work on within a period of a day or two. Then the therapists can observe how far these CI children have grasped the sounds and move on to another step. This method was observed within the sample set of this thesis and drastic developments could be observed.

3.1.3..Tips for Auditory â&#x20AC;&#x201C; Verbal Therapy at Home

The following details of this chapter basically deal with the therapy which parents at home can handle as they spend more time with their CI children. These small activities could be done formally and at the same time as informally in order to enhance the CI children grasp their L1 quickly. Although one could see these activities as very simple, they affect a lot in L1 acquisition process in CI children. Therefore, these activities should be promoted by the speech therapists and audiologists apart from their rehabilitation programmes. 32

3.2.3.1. Tips for formal Auditory – Verbal Therapy lessons at home

01 Children learn through play. 02 If it is not fun for you or your child, they will not cooperate or learn. 03 Make Auditory Verbal Therapy a 24 hour time for teaching. 04 Know your goals for the week so that you can incorporate them in everything you do 05 Sneak short lessons into the daily routine, e.g. 30 seconds for covering one goal " Do you own the pink tooth brush or the blue one" 06 Wait for your child's response signal expectation of an answer by tilting your head and raising an eyebrow. 07 Join in on your child's most favourite game and describe direct action and discuss as you play. 08 Model and expand your child's utterances with additional language and correct grammar if he says ―truck" you could reply " It's big truck .Look at the big wheels. I like that big red truck". Instead, we as Sri Lankans can make use of the word ―bus‖ for this because these CI children are not familiar with the word ―truck‖ and further it was identified that these Sri Lankan CI children are not that efficient in producing this retroflex /r/ sound, especially at the very beginning of L1 acquisition. Later they can be made familiar with some added adjectives like /loku/ (big) and then both together as in /loku bas / or /loku bas ekə/ (a big bus). Next they have used some phrases with regard to wheels, which is once again difficult for a Sinhala speaking child to produce /roɖəjə/. Therefore, it is advisable to talk about the length of the bus as /ɖigə/. Accordingly, necessary changes were adapted to suit CI children whose L1 is Sinhala. 09 Reward

appropriate

behavior

with

your

attention

and

discourage

inappropriate behavior by ignoring it. " Good talking I like the way you said " truck" 10 Read at least 2 books a day – 100 books a day if possible

3.2.3.2. Tips for informal Auditory Verbal Therapy opportunities at home

Fold the washing Sorting for young children can be based on using the possessive 's" e.g. " These are Daddy's Pants. Accordingly, the sample set of CI children were more comfortable when it was said ; /mɑge:/ (mine), because if the words mum‘s or dad‘s are directly translated into Sinhala they won‘t be the same as one syllable. Therefore, these CI children will be confused. It takes some more time with Sinhala speaking CI children than it is with English speaking CI children when considering this point as these children find it difficult to produce possessives like /ɑmmɑge:/ and /t :ttαge:/.

Another way of sorting is by colour pattern (checks, stripes etc) Length of sleeves, pant leg etc.

Matching pairs put 6 or 8 socks our and ask which ones are the same/ nor the same Ask for a certain sock of the group if an older child. Can I have the sock that has stars around the top? This point basically deals with commands where these CI children are being motivated due to the ease of saying these short phrases such as /maʈə dennə/ (give me). Initially, they will come out with only the action word (/dennə/)- (give) while they later on manage to come out with other words.

Wh questions can also be used as ways of sorting .Which pile do these go on? Where do these go? Who wears these socks? Whose socks are these? What are these gloves for? Although, these kinds of questions are proposed for the early development of CI children it was investigated that the CI children in this sample data found it more complex may be due to the language differences.

Plurals can be targeted "Put all the socks here. How many hankies are there? When it comes to this type of scenario these CI children will answer giving the number but it is once again debated whether it suits 34

the situation. For example normal Sinhala speaking children will answer that kind of question as /pɑhɑi/ but these CI children will say /pɑhɑ/ which denotes only the number but does not give any implication about the relevance to the situation. This is once again different from English language, because in English it is just /fɑiv/. It is the same as the number unlike in Sinhala. 06

Putting clothes away can be used as a way of following directions" Put these socks in the top drawer" Prepositions such as next to between, beside, behind in the corner, underneath and many more can be used.

Directions can be changed from simple to complex put the socks in daddy's cupboard in the second drawer.

Sabotage makes the session longer ―These socks go in the bottom drawer beside the hat isn‘t the hat in that drawer? Look in the drawer above that one is the hat in there?

Setting the Table

Possessives again can be covered" This is Mary‘s fork"

Simple and compound sentences can be used as directions ―Put the fork next to the napkin put the knife and spoon on the right and the fork on the left.

In a bottom drawer in the kitchen, have a plastic cup, bowl and plate ―Get out the cup. Get out the bowl and the cup. Get out the cup but not the plate." Increase contents of drawer to having a cup, bowl and plate in 3 colours. ―Get out the blue plate and the red cup."

Napkins can be folded to make rectangles. Squares and triangles. Once again in Sinhala the words which relate the shapes are very complex. Therefore, they are not given much prominence in speech but given in picture matching sessions and object matching sessions.

Sabotage again can be used to promote language. E.g. forget to have chairs at the table to put out food on the plate.

Have a plastic animal at the table or on the high chair. Give the toy animal something to eat as well as your child. Talk to the toy as you would to the child.

As stated above, different changes to these situations were made in order to suit our Sri Lankan context and Sinhala language.

Sitting in the car

01 Singing songs loudly. A tape of preschool songs could be made at music session at preschool next time. Under these they were made to listen to songs with easy words and with sets of repetitive words. 02 Get you older child to tell you which way to go " Turn left over the bridge Go straight ahead turn at the next corner, " Follow their directions and even make a mistake when you know what they say is wrong. They will learn to give specific directions. 03 Time words can be used. Before I start the car, put on your seatbelt while we are in the car we look for traffic signs. After we go to the shop, we will go the petrol station.

Waiting at the doctor

01 I spy with my little eye something that people sit on. 02 I'm thinking of something that has 4 legs. It is made of wood, it has books on it 03 Iâ&#x20AC;&#x2DC;m thinking of something in our kitchen it is white and cold on the inside it has a big door etc. 04 Hum a song "Can you guess what it is?" (Keep it simple at first) 05 Have 5 small stones. Close up hand. â&#x20AC;&#x2022;How many stones?" Give a quick look and close up hand again. Vary the number in your hand. 06 Take favourite books to read together. 36

07 Play what's missing? Take 3 toys from the toy basket cover with a scarf take one away without letting the child see it. 08 Draw shapes on bigger child's back. Guess which shape it is.

Taking a Bath and Swimming

Language opportunities can be lost at bath time and when swimming, because the child cannot wear amplification. Create the language opportunities at a different time. Use a bowl of water and wash a dolly as you would do to your child. The child then will replay those games himself in the bath. 1

Talk about body parts

Use action verbs

Using verbs

Talk about hot/ cold, wet/dry, in/out, under/over, back/front, floating/ sinking etc.

Washing the Dishes

This takes on new meaning when it is done in a bowl with warm water outside 01

Item selection can be done

Following directions

Maths concepts can be tested e.g. measuring volume, height, number of animals in a boat before it sinks, etc.1

Although all these parental activities are given according to CI children whose L1 is English, we being Sri Lankans can adapt changes to them in order to suit our culture and language. Therefore, some of the adjustments were made accordingly as they were used throughout this research. At the same time it is going to be another challenge for our parents as they have to be mindful as to how they are going to help these CI children to develop their acquisition level. Nevertheless, through these tips

Hear and Say Center

one could easily realise the work load or the level of commitment of the parents of CI children in order to make their HI children acquire language more appropriately. Once they become use to these they can automatically engage their CI children in day to day activities by giving them opportunities to expose themselves to language. Therefore, the CI users should be given constant proper guidance in the process of localization unlike a normal hearing child .This is also should be supported by parents. And these CI children should be trained to localize sounds which would later on make them localize alone when they get familiar to that action. For this, parents of CI children should make use of almost all the opportunities in their surroundings. See - Appendix 3 â&#x20AC;&#x201C; Video Clip No.4 - LLT1.f4V (Speech Therapy)1

3.3 â&#x20AC;&#x201C;Rehabilitation Process Furthermore, the rehabilitation process which should take place immediately after the CI also contributes a lot in developing the spoken ability of a CI child. The rehabilitators should always have good rapport not only with the CI children but it should be emphasised that they should have prompt connections with their parents, audiologists and the E.N.T. surgeons who are responsible of handling each CI child. Nevertheless, these speech therapists should be qualified enough to handle these CI children as they should be well aware of certain theories which are connected to language acquisition of normal as well as HI children and the teaching approaches and strategies with relevant to these CI childrenâ&#x20AC;&#x2DC;s psychology. Therefore, this chapter will also deal with the most appropriate teaching methodology and the strategies which could be incorporated in teaching CI children. When we talk about the methodology of teaching CI children one could assume that these methods and activities do not match our Sinhala language and our culture. But most of the therapists who trained the sample set of CI children made use of these methods very successfully in order to match our children. This gave great results in L1 acquisition. 1

http://www.cochlear.com/files/assets/videos/LLT 1.f4v

3.3.1. Developing listening skills in CI children.

The L1 development starts from listening first. Therefore, there were so many strategies which these therapists used in order to give a proper auditory input in these CI children. But before all these, CI children were tested by the audiologists for their proper audition levels after receiving the CI. This is very important for the therapists in order to develop the L1 perception within these CI children. Therefore, a brief explanation as to how it is tested is given below.

3.3.1.1. Testing Listening Skills

Initially, just after activation of the implant these CI children should be tested for their auditory input. This is done under several medical and physical observation assessments. When we talk about measuring their auditory levels they were checked under a specimen audiogram which is called as speech banana which includes all the possible speech sounds under several frequencies .This is called the aided hearing test and here are the following illustrations of them.

Figure 3.1 - Model of the aided audiogram

Nevertheless, these children are once again tested for their listening levels through their behavioural patterns and through their reactions in several stimuli based situations. For example, if they have reached the proper auditory input level they were able to turn their head towards the direction of the sound. With the help of these results speech therapists decide on the adjustments of the implant and if not necessary they will immediately begin speech therapy in order 40

to make the CI child grasp his or her L1 without any delay. Speech therapists first observe the levels of listening skills with implant age. Therefore, it is very essential to know about the standard abilities of CI children in order to make them achieve different stages.

3.3.1.2. The Sequential Development of Listening Skills

The following table gives an overview of implant-age appropriate listening skills, but it should be noted that these levels were not the same among every CI child as most of the CI children demonstrated so many differences in various perspectives mainly due to other disorders within them apart from the hearing impairment. Table 3.1 - Cochelear Implant Listening Skills Development

Cochelear Implant Listening Skills Development Guide to Rate of progress Development timings are only indicators and will vary according to the number of factors. after Stage1  Awareness of voice 1-4 weeks switch-on Awareness of  Awareness of environmental sounds (able Sound to localize sound)  Detection of ling sounds ('a', 'ee', 'oo', 'm', 'sh', 's')  Respond to own name (through listening alone) From 1-3 months : development of discrimination/ identification** of Ling sounds **Discrimination : the ability to perceive difference between two or more speech sounds. Identification : the ability to recognize a sound by repeating, pointing or writing what is heard. Stage 2 Pattern perception and non-language aspects 2-5 Months after Suprasegmental of speech switch-on Discrimination  Distinguished changes in vocal length and (duration : long & short) Association  Discriminate intensity/ pitch (loud & soft/ high & low)  Perceive difference in intonation/ stress/ 41

6-9

months after switch-on

Stage 3 Segmental discrimination & Association

9-18

Months postimplant

Stage 4 Identification

18+

Months postimplant

Stage 5 Progressing & Comprehension

rhythm/ rate  Imitating learning to listen sounds (Dogwoof, Cow-moo)  Perceive difference in word length (123+ syllables)  Discriminate sentence length (short phrases) Follow developmental steps for listening language and speech (refer to Listen, Learn & Talk, Cochelear 2003)  Discriminate constant and vowel difference in 1, 2 & 3 syllable words (ball. Apple, dinosaur)  Discriminate between increasingly similar words;  Consonant same, vowel different (boat, bat, bus; cat, coat, car; hat, hit, hot)  Constant different only by manner (house, mouse; bat, mat; far, sat) Identify:  1 keyword in context, with & without suprasegmentals  2 key words in context, in one sentence  3 key words in context, in one sentence  4+ key words in context, in one sentence  Advanced vocabulary development (expand categories, abstracts)  Increase word play association through listening  Answer simple questions (where, what, who)  Understand increasingly complex sentences with 3+ elements  Listen to short paragraphs and answer simple questions  Answer complex questions (how, why, what, next)  Listen to longer paragraphs and answer complex questions  Sequence with and without visual support like pictures and cards  Increase cognitive language skills (more complexity)  Follow conversation with familiar topic  Follow open-ended conversation (topic unknown; unfamiliar speaker)

Adapted from Shepherd Centre notes, Immediate AV course 2003 and from Childrens's Hospital, Oakland, Rate of Progress – Hear now And always CochlearTM

With some kind of understanding about these stages the speech therapists involve in teaching listening with the help of parents. Therefore, the following strategies are being followed.

3.3.1.3. Teaching Techniques and strategies to develop listening skills 

Be within hearing range. Sit on the child's better ear. Ensure you are speaking on a level opposite to his/ her hearing aid.



Start with easy to hear sounds.



Have extensive experience through play



Have high expectations expect that the child will hear



Parents must take part in the therapy sessions so that they learn what to do and can also be used as models for example, stimulus response activities it is necessary to have two adults when teaching the child the one making the sound must not respond; turn taking skills can be developed by using parents as models.



Auditory input first the spoken input is given before the toy / item is seen or before the toy moves.



Encourage children to vocalize before the toy moves or before they have their turn.



If the child vocalizes when working with toys and associated sounds, reward him/her by giving him/her the toy and then repeat the sound again to reinforce.



Have lots of repetition built into the game/activity.



Parents need to be given ideas for reinforcing in home setting so that meaningful interaction occurs.



Do a range of activities in a session to give parents a variety of ideas but let them know that they can spend a lot time on the one activity when playing at home.



Younger children can't play and listen. They can be rewarded after they have listened by playing with the toys. When they are older and good listeners they may be able to do both. 43



Integrate cognition – Even though a child's language and speech may be delayed, she can be challenged cognitively.



A barrage of auditory information is necessary before the child sees the object. Present the object in an interesting way so that there is the opportunity for a lot of repetition.



Allow time for the child to respond it is necessary to allow processing time



Change suprasegmental features – this makes the input more auditory available.



Move closer to the microphone and speak softly if there is difficulty with a particular sound not too close however and too close however and remember to use a quieter voice.



Don't have distracting noises when talking e.g. noisy toy.



Don't test very young children check incidentally whether meanings are being associated and identification skills are developing.



Achieve goals through play – However in the formal lessons it will be contrived play.



Have short term and long term goals.



Choose age and stage appropriate materials and activities which are interesting. Challenging and meaningful.



Establish age appropriate expectations for behaviors expect compliance.



Always be mindful of extending the child go one step further (Greater M.I.U. etc.)



Be mindful of extending both receptive and expressive skills.



Capture the child's attention.



Provide plenty of opportunity for the child to respond and expect him/her to respond to communication attempts – this is necessary to build up the ability to interact and is a part of conversational competence.



Expect closer and closer approximations until the target is consistently produced.



Provide plenty of opportunity for the child to respond.



Correct through audible contrasts to less audible ones.



Acoustically highlight to help a child hear a contrast but remember to put it back into natural rhythm. 44



Progress from more audible contrasts to less audible ones.



If you're unsure whether it's the listening or the conceptual aspect the child is having difficulty with have him her repeat what you are saying.



It is important for the teacher/therapist to learn to listen.



Integrate speech work into everything.



Don't interrupt child when speaking but if she leaves off a sound, for example, that you know she can do, then when she has finished talking, practice in speech babble and then put this back into the word and then into the sentence, e.g. us us us – bus bus- on the bus. 1

The above document brings some kind of curriculum in aiding listening skills within CI children. There were so many instances when therapists used most of these strategies in order to make these CI children aware of the sounds and due to that it was quite evident that they responded very well to some of the sounds within few weeks after the implant, but at the same time it was observed that whenever some of the CI children did not attend these rehabilitation programmes regularly they did not demonstrate much of an improvement in sound perception. Apart from these theories Ling-6 sounds has become another effective theory which has been identified through several researches. Therefore, these Ling-6 sound theory too was used by the therapists throughout this research in order to make these CI children aware of the sounds around them.

3.3.1.4 Signalling language acquisition through sound perception This was tested through the Ling – 6 sounds test which could be easily used by parents and therapists. Moreover, this test allows checking the CI child‘s feasibility in getting the minimal amount of sounds which are required to hear, learn and understand speech. The Ling-6 sounds represent various different speech sounds from low to high pitch (frequency). They help to test the CI child‘s hearing and

Ref ; S. Romanik.October 1997

check whether they have access to the full range of speech sounds necessary for learning language. The Ling-6 sounds are shown below:

3.3.1.4.1. Ling-6 sounds and examples of words containing these sounds:

m -mum ah -bath ee -bee oo -boo sh -fish s

-splash

The significance of these specific 6 Ling sounds was identified by several studies. Therefore, the researchers have found out reasons for this.

The Ling-6 sounds are the particular sounds that occur at particular speech frequencies or pitches. For example:

3.3.1.4.2. .Ling-6 Sounds and their frequency levels

m -/m/ is a very low frequency sound and if your child cannot hear this sound it is likely they will not have sufficient low frequency information to develop speech with normal prosody (tune) and without vowel errors. oo -/oo/ – [u] has low frequency information. ee

-/ee/ – [i] has some low frequency information and some high frequency

information. ah -/ah/ – [a] is at the centre of the speech range. sh

-/sh/ is in the moderately high frequency speech range.

-/s/ is in the very high frequency speech range.1

This shows 6-Ling sounds, along with other speech sounds, plotted on an audiogram. This shows both the frequency and the loudness of each sound. 46

Figure 3.2 - Ling-6 Sounds and their frequency levels

3.3.1.4.3. Acquisition of Ling-6 sounds To follow up the development of these Ling-6 sounds within CI children a model of a questionnaire was given to a focus group which consists of therapists, audiologists, E.N.T. surgeons, parents and so on. Here is a sample of it and this gives an idea of the process of data collection and about its implications. This questionnaire basically deals with the acquisition of Ling-6 Sounds. This is a quick and easy way to record your childâ&#x20AC;&#x2DC;s listening status and progress. Unlike other questionnaires this includes the name of the CI child because it could benefit the child to get appropriate therapy from therapists and audiologists.

Questionnaire 01 - Acquisition of Ling-6 sounds Recording the distance a sound is tested at:

Start at a distance on 20cm. As the child successfully detects the Ling-6 sounds, increase the distance between sound and the childâ&#x20AC;&#x2DC;s microphone. Through this type of testing it was found out that these CI children start hearing at a typical 47

speaking voice which is 50-65dB. A typical conversation would be identified by these CI children within a distance of 3 metres. This method of testing the hearing level with accordance to the distance made easy to track the progress of their listening levels.

Example: Distance tested at :..................... Presentation Level:

Recording the listening situation:

These CI children were exposed to listen at several environments such as in a quiet environment at the beginning and later on with distractions like the TV. These CI children were tested like this till they consistently repeats each sound correctly at a range of different distances. Then the records were:

Noisy situation OR

Quiet situation

Completing the check table: The child‘s responses to each following sound were tested in this. Table 3.2 - Check Table √ = Correct response — = no response Example ah

Monday

√

Tuesday

√

Wednesday

√

Thursday

√

Friday

√

Saturday

√

Sunday

√

Interpreting the above results:

This gives an overview of the beginning of L1 acquisition in CI children. Thereby it was evident that; /ah/ , /m/,/u:/ and /i:/ sounds were detected consistently and correctly. 48

But when it comes to /ʃ/ it did not give constant results. Nevertheless, very frequently these children were incompetent in detecting /s/ sound at all. This gives a clear implication that a CI child in the early stages, acquiring speech sounds takes a little more time to become accustomed to /s/ and /ʃ/ sounds rather than the other Ling sounds.

Through this type of daily checking, ability of language perception and its development was investigated.1

3.3.2. Developing Speaking Skills

Although the ultimate goal of this CI is language production, it cannot be straightaway achieved since it consists of several stages. Therefore, as the initial stage of L1 production, sound production can be mentioned. Before preparing these CI children to learn to produce sounds the proper knowledge of the following order of sounds and the places of their articulation is very important. Plosives and stops: a release of built up air pressure occurs with plosives; the pressure is not released for stops. p/b, t/d, k/g — green tabs 

Fricatives: a point of constriction causes friction in the breath stream that creates a sound. h, f/v, TH /th, s/z, sh/zh — blue tabs



Nasals: the breath stream goes mainly through the nose. m, n, ng — purple tabs



Semivowels: produced like vowels except there is greater constriction. w, y — yellow tabs



Liquids: the tongue diverts the breath stream in the mouth. l, r — orange tabs

Ling-6 sound test - how to.pdf (application/pdf Object) http://www.cochlear.com/files/assets/Ling-6%20sound%20test%20%20how%20to.pdf 49



Affricatives: a stop is released with a fricative. ch, j — red tabs Place of production is WH ERE a sound is made. Listed below are the different places, basic definitions and the consonants within each place of production:



Bilabial: two lips. p, b, m, w



Labiodental: bottom lip and teeth. f, v



Linguadental: tongue and teeth. TH , th



Alveolar: ridge on hard palate behind the upper teeth. t, d, s, z, n, l, r



Palatal: hard palate. sh, zh, y, ch, j



Velar: back of soft palate. k, g, ng



Glottal: back of mouth. h

All these sounds are made familiar in CI children repetitively through, different activities such as child friendly words, daily routines, using games and toys, songs, rhymes and finger plays and also through popular children‘s books.1

Accordingly, when we talk about rehabilitating these CI children to produce sounds there is no specific order of sound units but there are some general guide lines which most of the therapists stick to. As a result, normally these children are led to develop their language production starting with consonants. This is mainly because any normal child even starts producing language from consonants. For example, when they babble they come out with consonants like /b/ and /m/ very often as they say /bababa/ and /mamama/. Accordingly, sounds like m, b, y, n, w, d, p, h could be taken into account when we first expose a CI child to acoustics. On the other hand, phonemes like plosives and stops could be used very frequently. Although it is stated as above, it is the therapist who should work with the CI child to decide on the sounds which are more comfortable with him or her and then use them initially, because many CI children tend to show some kind of motivation to specific sounds. For example, they would love to hear the sounds in their names or sounds of their favourite food item.

Speech_Sounds.pdf (application/pdf Object) http://www.cochlear.com/files/assets/Speech_Sounds.pdf

3.3.3. Some Activities used in Rehabilitation Programmes The following set of activities was done at several speech therapy sessions and it was observed that how these CI children try to develop their language. Therefore, these activities could be used by other therapists to enable these CI children acquire language methodically.

Activity

TALKING TO CHILD

Age

0 months plus

Materials

Description

Encourage parents, siblings and family friends to talk or sing to child while feeding, clothing, bathing, or playing with him. When child shows awareness of voice by looking at speaker, child is given social reinforcement. Rhymes an fingerplays may be used to gain the child's attention. Refer to 'Fingerplays' found at the end of the activities section.

Activity

SOUNDS/ VOICE: AWARENESS

Age

3 months plus

Materials

Variety of loud, moderate and soft noisemakers; voice; soundproducing toys

Description

Present stimulus beginning with loud noisemaker (drum, cowbell, or loud voice) outside child's visual range within 6-8 inches from ear. a. If child shows awareness (stops activity, looks up, turns) show child the noisemaker, give social reinforcement, let child play with noisemaker. Repeat activity using progressively softer noisemakers or voice. b. If child shows no awareness, teach awareness using a drum or tambourine. Present stimulus outside visual range and continue to present stimulus while moving noisemaker into child's visual range. When child sees noisemaker, present

stimuli a few more times; allow the child to play with the noisemaker. Take noisemaker from child, with a few seconds and repeat entire procedure again starting with noisemaker outside child's visual range. Repeat until signs of awareness of sound are observed.

Activity

SOUNDS, AWARENESS, RECOGNITION, Comprehension

Age

6 months 3 years

Materials

Large cardboard box with flaps that open on one end and large hole cut in one side of box; any noisemaking toys: drum, bike horn, pull toys.

Description

Child sits in front of a closed box. Adult sits on other side of box and inserts a noisemaking toy into the box through hole. Adult presents sound in box. Child opens top of box and discovers noisemaking toy when he hears the sound. Let child play with noisemaking toy. The level of difficulty of this activity can be varied by using: noisemaking toys, b) softer noisemaking toys. This activity can are used to teach objectives involving voice as the auditory stimulus, sure putting a doll in the box and having the adult 'talk' for the doll.

Activity

VOICE: AWARENESS

Age

3 months plus

Materials

Blocks, puzzle, or a toy with several pieces

Description

For an infant, adult watches infant's behaviour as he is speaking to the baby outside of the child's visual range. Adult watches for changes in activity level, eye widening, smiling, ceasing of vocalizations, or turning of head toward adult. For an older child, adult will call the child's name and watch for the child to demonstrate he is aware of the sound. If the child is not aware of the sound, a second adult tells the child "Listen, I hear your name" and shows the child that the other adult is calling his name. The first adult may reinforce the child's auditory 52

responses by giving the child a block, puzzle piece, or part of a toy each time he responds to his name.

Activity

VOICE: AWARENESS, RECOGNITION, COMPREHENSION

Age

1 Year plus

Materials

Screen

Description

Present hides behind screen placed near child and teacher or other parent. Hidden parent begins talking to child, calling child's name and saying, "Hi! This is Mommy! Where's Mommy?" Other adult calls child's attention to the voice by pointing to ear, saying "Listen!" Parent repeats phrases, then steps out from behind screen and continues talking to child "Here's Mommy! I was talking to you!" Repeat Activity. Note: It is difficult to test recognition of voices in a very young child unless he consistently turns to correct speaker. See Activity 9 for testing recognition in older children.

Activity

PLAYING INTERACTION GAMES

Age

6 months plus

Materials

Description

play "Peek-a-boo", "S-o-o big", 'pat-a-cake" with child, helping him move through the actions. Consistently use one movement as the cue that the game is beginning, such as arms raising up for "So-o big" or hands clapping for "Pat-a-cake".

Activity

INFLECTIONAL PATTERNS TO CONVEY EMOTION

Age

2 Â˝ years plus

Materials

Tape recorded massages denoting affection, scolding or warnings; pictures of adult showing affection, giving warning, or scolding.

Description

This is best taught through natural experience. Let child listen to message on tape recorder or Language Master. Adult and child can imitate the phrase and find corresponding picture. Adults talk about feelings that are portrayed. Eventually, child would be

expected to point to appropriate picture independently and dramatize or describe feelings.

Activity

VISUAL REINFORCEMENT AUDIOMETRY

Age

6 months plus

Materials

Light, oscilloscope, or toy animal whose eyes light up when sound is presented; sound source, e.g. noisemakers, sound field speakers, voice.

Description

: (a) Training: Produce a sound and light simultaneously in front of child. Begin by using low frequency pure tone. After several presentations, wait until child is looking away from light before presentation of sound and light. Continue to present sound and light simultaneously until child consistently looks up at light when sound is presented. Move sound source out of child's visual range and continue to present sound and light simultaneously until child's response is consistent. (b) Testing: Move light out of child's visual range to vicinity of sound source. Produce sound while child is not looking at light. If child looks up or turns in response to sound, reward him with light. When attempting to determine thresholds, decrease intensity of sound until child no longer gives response. (Frequent retraining may be necessary) (c) When teaching localization put a sound source and light on either side of child. Present light reward only when child turns to correct source of sound. Note: A pure tone stimulus is preferable if possible for teaching VRA using a drum or other noisemaker may be distracting to the child.

Activity

ASKING AND ANSWERING QUESTIONS

Activity Number: 142 Age

3 Â˝ Years plus

Materials

Construction paper or felt pieces cut into various shapes 54

Description

Show the whole picture of a (bird, house) made out of felt pieces or construction paper pieces. Ask child "How can we make another (bird, house?)" "What colour is this one?' "How many pieces do we have?" "What is that?", "What happened?" Reconstruct another (bird, house) using same shapes. Start with a picture made of two pieces, then move to three, and then four pieces.

Activity

CLOTHING NAMES FOR THE OLDER CHILD

Number

143

Age

3 Â˝ years plus

Materials

Pictures of obvious summer clothes and obvious winter clothes cut from catalogued: Sandals, swimsuit, play suit, shorts, snowsuit, raincoat, hat, boots and umbrella.

Description

Have a number of pictures showing summer clothes or winter clothes. Show each picture to child, name the item and ask child if he would wear it on a hot summer day or a cold winter day. Paste summer clothes into a large piece of paper (adult can draw a big bright sun, flowers, and other seasonal pictures). Follow same procedure for winter clothes.1

To make these CI children like the learning environment these types of picture materials are being used in order to make them learn different sounds around them. This kind of material is suggested in order to match the age group of the sample set of CI children of this thesis.

Children Chatter, Listen Learn & Talk, Rehabilitation | Cochlear Australiahttp://www.cochlear.com/au/rehabilitation/listen-learn-talk/children-chatter

Pictures 3.1 â&#x20AC;&#x201C; Rehabilitation material

Ling cards.pdf (application/pdf Object) 56

3.3.4..Mainstream Education All the above effort of therapists and parents goes toward one specific goal which is sending these CI children to a normal school. Therefore, After these CI children get into mainstream education, those teachers too should pay more attention to maintain and develop the language skills of these children. If not, the hard work of the therapists would not be much useful. Therefore, the following tips will be very useful in helping these CI children grasp their education in normal schools.

3.3.4.1. Tips for teachers

What can I do to help children with Cochlear implants be successful? 

Ensure the cochlear implant is on and working



Reduce background noise in the classroom



Use carpeting, drapes, and non-sound reflective surfaces to absorb and reduce noise



Reduce fan noise, air conditioner noise, and television/radio/computer noise



Close the classroom door to eliminate distracting hallway noise



Use an FM System in the classroom to improve the speech signal in noise and provide the best acoustic environment



Position the child with a cochlear implant to be close to speakers



When speaking with a child, sit on the same side as the child‘s cochlear implant



Speak at a slightly slower rate when presenting new information



Explain to children what is coming up in discussions or studies



Don‘t raise your voice or shout; this distorts the speech signal, making it more difficult to understand. Rather, move closer to the child‘s cochlear implant.



Gain the child‘s attention prior to giving directions



Allow the child extra time to process auditorally

http://www.cochlear.com/files/assets/Ling%20cards.pdf



Repeat new vocabulary often and give alternative words when teaching new vocabulary



Use a buddy system with projects



Use written outlines to help the child follow directions1

3.4. Conclusion All the above facts bring out the importance of making these CI children aware of L1 input through the help of parents and therapists and how they should act accordingly to get the maximum benefits out of the cochlear which is implanted. Moreover, under L1 input, all the areas such as language perception, acquisition and production are being considered in this chapter. This chapter basically gave an idea as to how these CI children develop their language in a sequential order and that they initially begin with sound perception and then go on as producing sounds, later on words and utterances. Finally, they will definitely come out with their best performance in L1 production which enables them to learn in a normal school later in life. However, it was finally suggested the ways which these teachers should handle the rehabilitated CI children, when they come to a normal learning environment.2

http://journals.cec.sped.org/cgi/viewcontent.cgi?article=1008&context=tecplus

http://journals.lww.com/otology-neurology

Abstract/1991/05001 (Alexandra L.Quittner,PhD; Pamela Leibach,BS;Kristen Marciel,MS)

CHAPTER FOUR

LANGUAGE DEVELOPMENT IN CI CHILDREN 4.0 Introduction

The main focus of this thesis is on language acquisition in CI children. Therefore, this chapter deals with the main findings of L1 acquisition in these CI children. As the earlier chapter dealt with most of the methodology, which is related to language teaching within CI children, the findings will be brought out and analysed here. Nevertheless, through the implications one could draw conclusions in L1 acquisition within CI children. This will be really effective in making these CI children learn language. When it comes to language learning, much emphasis is given to areas such as language perception and production.

4.1 Introduction to Language Development

When talking about the significances of language development in CI children it is accepted that these CI children also acquire speech in much the same sequential order as normal hearing children, irrespective of their chronological age. 1 Evidently it was identified that these CI children also start with babbling and with vocal play as they become auditory aware after the CI. Later on, these CI children move towards jabbering as they identify rhythmic sounds. This is mainly due to the fact that they tend to register sounds easily when they are being heard repetitively. Therefore, the speech therapists as well as the parents could make use of this repeating strategy in making CI children aware of spoken language. After this jabbering stage they will try to produce words especially the ones which would be used in day to day life very often. This stage could be geared through enabling these CI children undergo several activities like matching labels, phrases with experience and objects. The findings of this research basically deal with the perception as well as the production of their L1 with relevant to the implantation of a cochlear. Specially, the 1

(www.cochlear.com/files/assets/rehab/early_intervention_6years/Auditoryskilldevelopment.pdf)

pre lingually hearing impaired children do not demonstrate any positive feedback with regard to their hearing ability soon after the surgery. This, once again leads the parents demotivate themselves as they come into very negative assumptions towards the CI device, which is totally incorrect since a child with a CI should undergo different stages of his or her language abilities after the implant. As it was recurrently mentioned in the earlier chapters, the language ability of a CI child should be improved with the help of so many people like parents, clinicians, speech therapists and teachers. Nevertheless, it was also proven that whenever a parent or a guardian of a CI child tends to get additional advice from another parent or a guardian who not only had children with CI, but who have grasped the language effectively and thereby who had been able to learn in the mainstream education like a normal hearing child, the efficacy in making those children grasp their L1 was really outstanding with contrast to the other CI children. Nevertheless, these CI children tend to produce utterances after some time of training but it was evident that they do so only when they are being stimulated. That means during the onset of language acquisition of a CI child, one could hardly observe even some involvement of spontaneous speech rather it should be stimulated. The sample set of children was linguistically analysed in order to find out the efficacy

of their language perception. It was quite fortunate to get to know them

from the initial stage of the CI surgery which led to identify the improvements of their language acquisition from the beginning. Therefore, enough evidence was gained about language development of CI children, through these HI, CI, children. The following types of audiograms helped a lot in proving the developmental stages in L1 acquisition scientifically.

Figure 4.1 - Audiograms Audiograms An audiogram is a graph. Loudness is measured in decibels (dB). dB on an audiogram is called 'Hearing Level'. 10dB is quiet and 100 dB is loud.

The numbers called 'Frequency' are the pitch. A small number is a low sound and a big number is a high sound. Speech is made of different sounds. Speech sounds can be drawn on the audiogram. They are between the 10dB and 60dB lines Vowel sounds like oo, ah, ay and ee are low and loud. Sounds like m, n and ng are low but quiet. Other sounds like d, t, s, f and th are high and quiet.

Words with no high sounds are hard to understand. eg

(Can you understand this?) Copyright Wendy Pallant 2001

uera

i?'

4.1.1- Language Development and Age at Implant

The following description and the tables will definitely enable a person who is highly interested in getting to know the developmental stages of language acquisition within a normal child. Therefore, it was very much helpful in analysing L1 acquisition of CI children with the use of this data. These tables are an integrated scale that outlines typical stages of development in the areas of listening, receptive and expressive language, speech, cognition and social communication. Children with hearing impairment follow these stages of development. However, They will need greater exposure to spoken language from the earliest possible time. Language, speech, cognition and pragmatic skills should be developed concurrently through listening in a systematic programme that follows the typical stages of development. Nevertheless, it should be once again insisted that these stages are based on an average. There is a considerable range between the earliest and latest times children achieve the various milestones. Therefore, some children may not reach a milestone within the given timeframe, but this does not mean that they will not achieve it. These developmental scales are meant as a guide only.

Table 4.1 â&#x20AC;&#x201C; Sounds of Speech

Sounds of Speech Sound

Age Acquired (year) 1

Vowels

vowels

popcorn

mommy

happy

water

baby

cake

daddy

tomato

ring

funny

yellow

rabbit

lion

sun

cheese

shopping

zebra

jack

velvet

think

those

pleasure

th TH zh

*Typical average upper age limits of consonant production

Listen-Learn-and-Talk.pdf (application/pdf Object), http://www.cochlear.com/files/assets/ListenLearn-and-Talk.pdf

Tables 4.2 - Stages of Language Development In Children

Stages of Language Development In Children 0 to 3 Months Listening (Audition)  Auditory awareness  Responds to sound by smiling, head turning, stilling, startling  Responds to loud sounds  Recognizes mother's/ caregiver's voice

Receptive Language  Startles to sudden noises  Responds to speaker's face Responds to talking by quietening or smiling  Quietens with familiar voice

Social

Expressive

Speech

Language  Cries to express hunger and anger  Begins to vocalize to express pleasure  Occasionally vocalizes in response to voice like sounds

Cognition

Communication (Pragmatics)

 Cries  Begins vocalizing other than crying, e.g. coos, gurgles

 Awareness of familiar people/situations  Looks at objects/faces briefly  Anticipates certain events, e.g. being fed

 Appears to listen to speaker  Has brief eye contact but by 3 months regularly looks directly at speaker's face, localizes speaker with eyes and starts to watch mouth rather than whole face  Smiles/coos in response, in particular to mother/caregiver

4 to 6 Months Listening (Audition)  Sound begins to have meaning  Listens more acutely  Starts to associate meaning to sound, e.g. responds to own name occasionally  Responds to changes in vocal inflections  Starts to localize source of voice with accuracy  Listens to own voice

Receptive Language  Frequently localizes sound source with head or eye turn  Occasionally responds to own name  Discriminates between angry and friendly vocal tones, e.g. cries in response to an angry voice  Usually stops crying in response to voice

Social

Expressive

Speech

Language  Vocalizes for needs and wants  Vocalizes in response to singing  Blows raspberries, coos, yells  Vocalizes in response to speech  Starts to use a variety of vocalizations to express pleasure and displeasure  Vocalizes when alone or with others

Cognition

Communication (Pragmatics)

    

Laughs Blows raspberries Coos Yells Starts to change duration, pitch and intensity (prosodic features)  Uses vowel [a] as in car  Produces sounds with consonant features - friction noises, nasal [m]  Plays at making sounds

 Looks at objects and reaches for them  Starts to learn about cause and effect, e.g. plays with rattle  Recognizes familiar people  Brings objects to mouth

 Maintains eye contact  Loves games such as round and round the garden  Produces different vocalizations for different reasons  Imitates facial expressions  Takes the initiative in vocalizing and engages adult in interaction  Starts to understand vocal turn taking, e.g. vocalizes in response to adult vocal input

7 to 9 Months Listening (Audition)  Localizes sound source with accuracy  Discriminates suprasegment al aspects of duration, pitch and intensity  Has longer attention span  Associates meaning to words  Discriminates vowel and syllable content

Receptive Language

Expressive Language

Speech

Cognition

 Appears to recognize names of family members in connected speech, even when person named is not in sight  Responds with appropriate arm gestures to such words as up, high, bye bye, etc.  Enjoys music or singing  Appears to listen to whole conversation between others  Regularly stops activity when name is called  Appears to recognize the names of a few common objects by localizing them when they are named  More regularly stops activity in response to "no"  Will sustain interest up to a minute while looking at pictures or books with adult

 Repeats CV syllables in babble [pa pa]  Starts to respond with vocalizations when called by name  Plays more games, e.g. pat a cake, peek a boo, hand clapping, etc. and vocalizes during games  Appears to "sing"  Vocalizes to greet a familiar adult  Calls to get attention  Uses some gestures and language appropriately, e.g. shakes head for "ho"  Vocalizes loudly

 Babbles CV CV [pa pa] [ba ba]  Clicks tongue  Uses a "singsong" voice  Imitates patterns of intonation  Uses low central vowels most frequently [o] (hot) [ae] (bat) [a] (car)  Uses some consonants [p, b, m, d]

 Imitates physical action  Recognizes familiar objects  Places object in one hand and then the other  Holds one cube and takes another  Smiles at self in mirror  Loves hiding and finding games  Gives, points, shows  Pulls rings off peg

Social Communication (Pragmatics)  Begins to understand that communication is a two-way process  Shows a desire to interact with people  Becomes more lively to familiar people  Demonstrates anticipation of activities  Nods, waves and claps  Calls to get attention  Requests by reaching and pointing  Enjoys frolic play  Continues to develop turn taking skills  Begins book sharing by looking at pictures in a book with adult

10 to 12 Months Listening (Audition)  Associates meaning to more words  Monitors own voice and voices of others  Localizes sound from a distance  Discriminates speaker's voice from competing stimuli

Receptive Language

Expressive Language

Speech

Cognition

 Appears to enjoy listening to new words  Generally able to listen to speech without being distracted by other competing sounds  Occasionally gives toys and objects to adult on verbal request  Occasionally follows simple commands, e.g. Put that down.  Responds to music with body or hand movement in approximate time  Demonstrates understanding of verbal requests with appropriate head and body gestures  Shows increased attention to speech over prolonged periods of time

 Uses jargon of 4 or more syllables – short sentence-like structures without true words  Starts to use varied jargon patterns with adult intonation patterns when playing alone  Initiates speech gesture games such as round and round the garden  Talks to toys/objects using longer verbal patterns  Frequently responds to songs or rhymes by vocalizing  Imitates action paired with sound  May use first words, e.g. bye bye, mama

 Imitates sounds and number of syllables used by others  Uses suprasegmenta l features  Uses longer strings of repeated syllables  Vowels and consonants are systematically varied [ba di ba di]  Mostly uses plosives and nasals [p, b, d, m]

 Resists when toy is taken away  Relates an action to an object, e.g. spoon with stirring, car with pushing  Responds to laughter by repeating action  Takes peg from peg board  Matches two identical objects  Attempts to build a two block tower

Social Communication (Pragmatics)  Starts to understand question and answer, e.g. shakes head appropriately for "no"  Understanding of interaction continues to develop  Understands greetings  Turn taking skills continue to develop  Vocalizes in response to mother's call  Indicates desire to change activities  Responds to laughter by repeating action  Begins directing others by tugging, pushing  Vocalizes with gesture to protest  Enjoys games and initiates them

13 to 15 Months Listening (Audition)  Identifies more words  Processes simple language  Auditory memory of one item at the end of a phrase/sentence  Discriminates between familiar phrases  Follows one step directions that are familiar

Receptive Language  Understands more new words each week  Follows one step directions during play  Understands simple where questions, e.g. Where's daddy?  Recognizes and demonstrates understanding of many objects by pointing  Understands more familiar phrases o Begins to recognize names of various body parts, e.g. eyes, hands  Enjoys rhymes

Social

Expressive

Speech

Language  Uses 7 or more words consistently  Uses voice and gesture to obtain desired object  Continues to use jargon with more true words developing  Incorporates pausing and intonation into jargon  Imitates new words spontaneously  Sings

Cognition

Communication (Pragmatics)

 Imitates alternated vowels  Approximates single words  Uses most vowels in vocal play  Uses more front consonants plosives [p, b, d], nasals [m, n]  Uses fricative [h]  Uses semivowel [w]

 Sustains interest in desired object for two minutes and more  Places circle in shape board  Builds a tower with two cubes  Begins to make marks on paper with thick crayon  Imitates more actions, e.g. patting doll  Demonstrates functional use of objects  Removes lid of box to find hidden toy

 Continues to develop eye contact with speaker for longer periods  Takes turns as expressive language develops  Plays fetching game  Involves others by showing things, e.g. shoes/clothing during play  Begins to understand "wh" questions

16 to 18 Months Listening (Audition)  Discriminates between more phrases  Identifies and associates more words to related objects, e.g. toys, body parts, food, clothing  Imitates words heard

Receptive Language  Understands more simple questions  Begins to understand longer phrases with key word in middle of sentence  Develops category vocabulary  Identifies more body parts  Finds familiar object not in sight  Understands 50 or more words  Identifies some clothing items, toys and food

Social

Expressive

Speech

Language  Jargon disappears  Increases vocabulary, 10 or more meaningful words  Decreases use of gesture – relies on talking to communicate  Imitates words heard  Asks for more

Cognition

Communication (Pragmatics)

 Increases single word approximations  Most vowels present  Still mainly producing front consonants [p, b, d, m, n, h, w]

 Imitates circular scribble  Places 3 to 6 pegs in pegboard  Retrieves desired toy from behind an obstacle  Picks up small objects  Turns bottle upside down to obtain toy  Points to pictures in a book and begins to turn pages  Demonstrates object permanence

 Requests object or help from adult by gesturing and vocalizing  Initiates vocal interaction  Prefers to be with familiar people  Shows caution with strangers  Imitates other children

19 to 24 Months Listening (Audition)  Auditory memory of 2 items  Discriminates songs  Comprehends a variety of phrases  Discriminates descriptive phrases  Follows a two step direction, e.g. Get your ball and throw it.  Identifies by category

Social Receptive Language

Expressive Language

Speech

Cognition

Communication (Pragmatics)

 Completes two requests with one object  Chooses two familiar objects  Comprehends action phrases  Points to a range of body parts, e.g. elbow, cheek  Begins to understand personal pronouns – my, mine, you  Recognizes new words daily  Increases comprehension decodes simple syntax  By 24 months understands 250 – 300 words

 Occasionally imitates 2 - 3 word phrases  Uses new words regularly  Increases expressive vocabulary to 30 words or more  Attempts "stories" – longer utterances in jargon to get message across  Begins to use own name when talking about self  Uses possessive pronouns – mine  May ask where questions Where car?  By 24 months may use 2 - 3 word phrases with nouns, some verbs and some adjectives

 Approximates words  Substitutes /w/ for /r/  Uses suprasegmental features  Most vowels and diphthongs present  Consonants [k, g, t, ng] emerging  Consonants [p, b, m, h, n, d] established – used in initial position in words  Consonants often omitted in medial and final position

 Imitates symbolic play, e.g. household activities  Uses one object as symbol for another  Places triangle, circle, square in shape board  Imitates vertical strokes  Threads three beads  Begins to tear paper  Imitates ordering of nesting cups  Begins to categorize objects in play  Uses two toys together  Stacks blocks/builds tower  Completes simple pull out puzzle  Activates mechanical toy

 Begins to develop more self confidence and is happy to be with other people  Initiates pretend play  Responds to requests from adults  Practices adultlike conversation about familiar themes  Uses words to interact  Requests information, e.g. What is this?  Develops turn taking in conversation

25 to 30 Months Listening (Audition)  Auditory memory of 2 items in different linguistic contexts  Listens to familiar songs on tape  Compreh ends longer utterance s  Listens from a distance

Social Receptive Language

Expressive Language

Speech

Cognition

Communicatio n (Pragmatics)

 Begins to understand complex language  Comprehends more complex action phrases  Understands functions, e.g. What do we use for drinking? – points to cup  Begins to understand size differences, e.g. big/little  Begins to understand prepositions, e.g. in, on, under  Receptive vocabulary increases  Begins to understand concept of quantity, e.g. one, all  Understands pronouns, e.g. he, she, they, we

 Uses 2 - 3 word phrases more consistently  Uses some personal pronouns, e.g. me, you  Asks for help using two or more words, e.g. wash hands  Begins to name primary colors  Refers to self by pronoun me  Repeats 2 numbers counting  Answers "wh" questions, e.g.. What's that?, What's … doing?, Who?  Recites nursery rhymes and favorite songs  Understands and answers "can you". Uses negation, e.g. don't, no

 Loves experimenting with prosodic features  Begins to use stress correctly  Repeats words and phrases  Consonants [f, y] emerging  Consonants, e.g. [m, p, b] used in final position  Word/phrases shortened– medial consonants often omitted  Tends to over pronounce words  Different pronunciation of the same word occurs frequently  Whispers

 Continues symbolic play, e.g. talking on the phone  Completes actions, e.g. clap hands and high 5s  Uses toys appropriately  Performs related activities at play  Turns one page at a time  Imitates vertical, horizontal lines and circle  Matches identical picture to picture and shape to shape  Puts two parts of a whole together  Understands number concept of one and two

 Enjoys talking, e.g. pretends to have a conversation on the phone  Completes actions, e.g. Give me five  Begins to develop parallel play with other children  Talks more in play  Shares toys  Asks for help using two or more words  Uses longer utterances

31 to 36 Months Listening (Audition)  Continues to expand auditory memory – 3 item auditory memory with different linguistic features  Sequences 2 pieces of informatio n in order  Listens to stories on tape  Follows 2 -3 directions

Social Receptive Language

Expressive Language

Speech

Cognition

Communication (Pragmatics)

 Understands most common verbs  Understands and responds to more complex language and commands  Carries out 2 - 3 verbal commands in one sentence  Understands several prepositions, e.g. in, on under  Expands concept development  Identifies parts of an object  Understands time concept, e.g. today, yesterday, tomorrow  Understands What is missing?/Which one does not belong?

 Knows gender vocabulary  Talks about what has drawn  Gives both first and last name when asked  Relates recent experiences  Converses in 3 – 4 word simple sentences  Begins using more complex language  Uses questions, e.g. who, what, where, why  Uses pronouns, e.g. he, she, they, we, you, me  Uses some plurals  Uses possessives  Uses more negatives, e.g. not, none, nobody  Begins to use and/because  Names three or more colors

 Makes some substitutions [f] for [th], [w] for [r]  Medial consonants still inconsistent  Final consonants inserted more regularly  Consonants [l, r, sh, s, z, ch] emerging  Vowels and diphthongs established  Omits some unstressed parts of speech  Pronunciation becomes more correct  Whispers frequently

 Shares toys and takes turns more appropriately  Develops parallel play  Begins to develop interest in writing and drawing  Begins fantasy play  Matches six color cards  Sorts and categorizes, e.g. blocks and pegs  Names object when part of it is shown in a picture  Adds two missing body parts to a drawing  Shows interest in how and why things work  Completes 2 – 3 interlocking puzzle pieces  Imitates drawing a cross

 Takes turns and shares  Recites rhymes  Acts out songs sometimes changes endings  Engages in make-believe activities  Begins to ask permission of others  Expresses feeling  Initiates conversation  Uses questions for a variety of reasons, e.g. to obtain information, to request

37 to 42 Months Listening (Audition)  Auditory memory increases to 5 items  Sequences 3 or more pieces of information in order  Retells a short story  Follows 3 directions  Processes complex sentence structures  Tracks a 6 word sentence

Social Receptive Language

Expressive Language

Speech

Cognition

Communication (Pragmatics)

 Can listen to a 10 – 15 minute story  Comprehends an increasing level of complex language  Understands more difficult concepts, e.g. quality, texture, quantity  Understands concept of day/night, e.g. distinguishes day from night activities  Follows directions using concepts of empty/full, same/different  Understands locational prepositions, e.g. next to  Begins to understand comparatives, e.g. I am taller than you.  Understands about 900 words

 Holds conversations using many correct grammatical structures (plurals, possession, pronouns, prep, adj.)  Uses "when" and "how many" questions  Uses so/because  Relays a message  Describes what objects can be used for  Starts to answer "what if?" questions  Answers What is missing?  Identifies which one does not belong and answers Why?  Attempts to answer problem-solving questions, e.g. What if?  Uses about 500 intelligible words

 Uses some blends, e.g. [mp, pt, br, dr, gr, sm]  Consonant s [j, v, th] emerging  Some substitutio ns still made, e.g. [gw] for [gr] in blends  Pronunciat ions of words more stable from one production to the next

 Begins one-to-one correspondence  Follows directions using concepts, e.g empty, full, same, different  Develops more difficult concepts, e.g. quality, quantity, texture  Compares objects  Begins simple problem solving  Develops imagination

 Takes turns  Plays with other children more appropriately  Shows understanding of others' feelings/needs  Interacts through simple conversation  Initiates conversation  Enjoys role-plays

43 to 48 Months Listening (Audition)

Receptive Language

Expressive Language

Speech

 Processes longer and more complex language structures, e.g. Can you find something that lives in a tree, has feathers and a yellow crest?  Follows directions with more difficult concepts, e.g. Put the thick blue square behind the empty jug.  Re-tells longer stories in detail 5 or more sentences  Tracks an 8 word sentence

 Continues to expand vocabulary comprehension  Understands singular/plural  Understands difference between past/present/ future  Answers final word analogies  Identifies objects missing from scene  Understands day/morning/ afternoon/night  Makes comparisons of speed/weight  Understands 1500 - 2000 words

 Uses his/her/their  More consistent use of plurals – irregular and regular  Talks about pictures and story books  Uses more sophisticated imaginative play  Uses negatives and some modals, e.g. shouldn't/ won't/ can't  Uses comparisons  Makes inferences  Develops colloquial expressions  Uses How much? How? questions  Uses 800 - 1500 words  Uses more complex language structures  Spontaneous utterances are mostly grammatically correct

 Reduces omissions and substitutions  Most consonants established  More blends emerging in initial and final position  Rate and rhythm normal  Uses appropriate loudness level  Uses appropriate intonation  For accompanying chart

Listen-Learn-and-Talk.pdf (application/pdf Object), http://www.cochlear.com/files/assets/Listen-Learn-and-Talk.pdf

Social Communication (Pragmatics)  Draws simple  Increases objects confidence and self esteem  Understands time concepts, e.g. .today/  Requests made tomorrow/ from others, e.g. yesterday/ morning/ shop/retail assistant afternoon/ night  Uses intonation appropriately  Tells how many fingers and toes  Initiates conversation  Associates an object with an occupation,  Adapts to changes e.g. of topic thermometer/doctor  Uses language for  Continues to different develop imagination communicative intent, e.g.  Concentration increases obtaining information, giving  Copies simple information, picture line drawings expressing  Matches patterns needs/feelings,  Makes inferences bargaining Cognition

Nevertheless, the earlier days of this research dealt with how age at implantation affects language acquisition and later on it was proven that most of the HI children who received a CI between the age of two and two and a half years performed well in language perception as well as in language production in comparison to children who received their CI, when they were four years of age. This does not mean that the children who received the CI later in their life did not grasp their language at all, but it is a matter of pace in acquiring their L1. At the same time it was quite evident that the HI children who received their CI later in their lives demonstrated language without suprasegmental features. Thereby, they did not have proper stress and intonation patterns in their speech as of a normal hearing child. This makes these children produce language rather mechanical and far from natural speech. Except for the variations in the speech production there could be several other characteristics which have affected these CI children due to later implant. Accordingly, children who received a CI early in their life could be taken as X and the children who received a CI could be taken as Y for the ease of analysing henceforth in this thesis. Thus, both the X set of children and the Y set of children in this research received their CI during the same course of time and their onset for the rehabilitation programme was also the same. Therefore, it was quite easy to analyse the collected data. As it is mentioned from the beginning of this research a CI itself would not at all be supportive for a hearing impaired child to gain his or her speech ability mainly in the field of perception, which later on leads to the ability of spoken language. Therefore, the auditory input at proper age should take place in order to overcome the other hardships which are faced by a hearing impaired child. Thus, the parents should be very much vigilant with their newly born babies as this age appropriate factor makes so many advancements in this particular CI surgery. Some would believe that merely a CI being transplanted at any time of life would make a hearing impaired develop his or her language ability. This misconception has taken place due to various reasons, but mainly due to the fact that people are not given proper understanding about this area of CI surgery. Moreover, these types of awareness programmes are not being conducted widely because, they are known among only a few set of people due to the high cost it takes.

When the age factor is considered with regard to the efficacy in L1 acquisition of CI children, it could be taken as the steering factor towards success of language development and specially in its pace, since there is so many positive evidence in L1 acquisition with infants rather than with toddlers. When it comes to the age factor it is once again recommended to identify the hardships of hearing within a child in the earliest of its age, rather than delaying it. .

4.1.2. Cause for a specific age limit with regard to a paediatric CI

Of all the factors that influence the outcomes of paediatric CI, age at implantation seems to be one of the most robust factors, especially in relation to oral language acquisition. The process of language acquisition in a hearing impaired child is hindered mainly due to the failure of the ability to discriminate speech sounds from other noises around them, even after getting the ability to hear properly with the help of a CI. Normally a hearing impaired child is deprived of the sense of hearing with regard to the disorders in the cortical connections within the brain. Thus, the maximum benefits of a CI could be gained only if it is inserted and activated before the cortical reorganizing takes place. On that basis neurophysiologic studies suggest that a sensitive period for normal language development lasts until three to four years of age.1 Unless a child is exposed to sounds he or she becomes deprived of language perception and thereby, that child hinders language production too. Therefore, a hearing impaired child should be enable to hear the sounds and then to discriminate them accordingly. Then with the exposure, those children will be motivated to produce language as time goes on. Although most studies pay more attention towards the deprivations caused post natally with regard to hearing impairment, there are so many issues which are connected due to prenatal factors too. This is mainly proven through medical researchers, that normal hearing babies tend to hear several sounds like motherâ&#x20AC;&#x2DC;s blood circulating and sounds of digestion. Nevertheless, among all these sounds they have the ability to discriminate their parentsâ&#x20AC;&#x2DC; voices and music, which is an advance process. Thus, parents should always be vigilant and quick in

(Speech and Sign Perception in Deaf Children with CI by Marcel Giezen)

making decisions about their HI children, since it affects a lot in the efficacy of language acquisition, as benefits of post implant.

4.2. Findings about the efficacy of CI with relevant to the age factor.

4.2.1 Age at diagnosis of HI

How age at diagnosis of hearing impairment, could affect a child in his or her language acquisition was observed throughout the research simultaneously with other relevant factors. Thereby, it was made easy to reach so many assumptions which relate most of the literature stated above, but at the same time there were some other assumptions which were not really mentioned in the earlier findings, still they possess some truth within them. When it comes to the identification of the hearing impairment of a child, it is advised to be as early as possible, since this would lead to provide with early, effective medication. However, once the sample set of parents were interviewed, it was implied that, although it carries a positive note scientifically, knowing about their new born babyâ&#x20AC;&#x2DC;s disability as early as possible has deprived them of enjoying the anxiety of their child birth. Nevertheless, most of the parents complained that going behind medication in order to overcome the hearing impairment of their child, rather than spending a normal family life by caring their baby and giving him or her the affection the way a normal child gets, has later on led to distress of parents and at the same time it has shown some unrest even within the baby although he or she is unable to express at that stage. Still, the suppression could be identified through the abnormal, aggressive behaviour of those children even later in life, due to the fact that they were unable to fulfil most of their age appropriate biological and psychological needs. They begin to hurt their mothers as the very first occasion of reaction. This type of rude behaviour could be identified later on towards his or her colleagues. This becomes a social problem when that child intrudes into mainstream education. Therefore, as parents they should be able to balance their activities to suit their childâ&#x20AC;&#x2DC;s mentality even from the infancy, rather than aiming only at making their child acquire the language. Apart from these negative effects with regard to early identification of hearing impairment, many other benefits are recorded throughout these years by researchers. Therefore, it is advisable to take 77

necessary actions as soon as possible in recognizing the age at onset of the hearing impairment and in implanting the CI. Nevertheless, it should be understood that immediate transitions in hearing within the child could not be observed even though the surgery is done in infancy. But due to the functioning of the cortical, this lower age limit is very much accepted.

4.2.2 Age at cochlear implant

Talking of age factor in the light of CI, efficacy of it could be judged in different angles such as, age at onset, age of diagnosis, age at implant and the duration rendered for rehabilitation.

When it comes to diagnosis, the hearing

impairment from heredity could be identified very early in life of an infant. Those who have diagnosed this before the age of two, show a considerable development in the growth of language perception as well as in language production after receiving a cochlear implant with comparison to HI children who receive a CI later in their life. The children who are hearing impaired through heredity, tend to use sign language from the very beginning if they are not being exposed to a CI immediately, as it could be familiar within his or her family. Suppose by any chance if a child gets used to these alternative ways of expressing ideas, it would be very difficult for them to get educated in the mainstream , even after a CI. Nonetheless, they should not be motivated to depend on lip reading unless it is just after the CI. Still they should be trained to discriminate the sounds around them, with the use of the implant. They should be trained to identify speech sounds from other noise around them. This was quite evident when these CI children were taken to therapists. Because these therapists used to cover their mouth and then produce sounds for this CI child to hear. At the beginning they struggled to grasp these sounds or at times they did not have any sense towards these sounds. But later on they were trained to grasp what is being told by a person irrespective of the distance he or she has within the sound. Another advantage of a child to receive a CI early is not only in the field of perception, but the sounds he or she is aware of, could be easily produced rather than the children with a CI later in their life, mainly after the critical period specially suggested for the hearing impaired. The children who receive a CI later after the critical period show ability more towards language perception, as it could be 78

identified through their behaviour in carrying orders properly, rather than in language production. But when it comes to children with a CI, before the critical period of language acquisition, their growth in language development in both perception and production is far more advanced than that of the children who received a CI after their critical period of language acquisition. This research also deals with a family, where the father is hearing impaired and his daughter too has been hearing impaired through heredity, although the mother is of normal hearing. That father has undergone a surgery when he was fifteen years and he has not been able to acquire language till he is about thirty. That is mainly due to the fact that he has passed the sensitive periods of language acquisition in his infancy. However, he has managed to acquire oral language over time, as some people could gain benefits as time goes on with a CI, since this is a process which researchers still have not been successful in figuring out any kind of uniformity, in its results. Thus, he has been unable to activate his cortical connections within the brain, and due to that he had been deprived of exposure to sounds, which made him unable to acquire or produce language. Therefore, he has made his daughter receive a CI as soon as possible that is before she became two years old, which has led to very good results in language acquisition of his daughter unlike him. Now this daughter has entered into mainstream education and leads almost a normal life. This example once again proves the efficacy of having a CI within the critical period of language acquisition for hearing impaired that is before two years of age. Although emphasis is given to language production, it is not intended for the parents to experience it in the fullest scale at the early stages of the implant , because at the very early stage a CI child is able to produce a limited set of sounds as stimulus given by the caregivers, instead of spontaneous speech. The sample set of children were roughly divided into two groups basically for the ease of analysing, how this age factor affects language acquisition of HI, CI children. One set of children was grouped concerning their age at implant, where some children were categorized as they had received a CI before the age of two years and nevertheless most of them had been congenitally deaf ,which once again could be sub categorized as in deafness through heredity and non heredity. The other set of children was of more than four years of age when they received the CI. Although, the difference between the two age groups do not make a vast difference, the effect 79

created due to that subtle difference is very much significant in the arena of language perception and production. There was a significant difference in speech recognition as well as in speech production, between those who received their implant between the ages of two and four. This was further proven when it was compared with children who received the implant after four years of age. At the same, time they were not congenitally deaf either. This set of children has become hearing impaired later in their life due to meningitis and they had been normal in language perception and production before this impairment. Meningitis is a disease which is caused due to a bacterial or viral infection .It is a disease that can cause hearing loss or even kill a person. Due to meningitis, the tissue covering the brain and spinal cord swell up.1But still, even after the cochlear implantation, they demonstrated a rather slow progress in language perception and production with comparison to children who received a CI early before two years of age. Although it is suggested that, CI children with post lingual onset of deafness have better auditory performance than children with pre lingual onset,2 it was opposed due to some of the findings through this research. In this sample study there were some children who had had normal hearing from birth and became hearing impaired due to meningitis. They received a CI after the age of four but were not that successful in acquiring the language which they had been exposed to, within the past few years. They had been deprived of hearing only for about one year and during that period they have lost the potential to talk. Therefore, those parents also undergo the same distress of other parents of HI children by giving them rehabilitation programmes. Accordingly, large individual differences can be observed through this research, although it is expected to gain a unique conclusion. Overall, the results showed a strong combined effect of age at implantation and the length of time the children had had their implant.

4.3. Language Development and Rehabilitation

Considering Language development and the rehabilitation process the relevant facts and methods which associate were clearly elaborated in the earlier 1 2

.( www.fda.gov) (www. Medhelp.org/lib/100coc.htm)

chapter. Therefore, this chapter analyses the development process of L1 acquisition within these CI children after these activities. It was observed how both these sets of children managed to train themselves to discriminate voices from other noise in their surrounding and it was undoubtedly the effort of the speech therapists who took all the pain to make them aware of those sounds since these children have never been able to experience these kinds of acoustic cues in their lives. Therefore, the teachers and the speech therapists made use of almost all the teaching methods to familiarize the CI children with the sounds within their surroundings. For example, the teachers and the speech therapists who were responsible in the process of rehabilitation made use of either picture-matching exercises or object â&#x20AC;&#x201C; matching exercises in order to familiarize the CI, HI children with the word of specific objects. For instance suppose those CI children are to figure out the sound of an aeroplane, then these teachers made use of the realia on the spot which led to the method of object- matching followed up with the sound /plane/ produced by the teacher closer to the ear of the CI children which later on got registered in their mind after some repetitive occasions. Later on these CI children tend to point at the aeroplane as soon as they hear an aeroplane going up in the sky. Then they were also given a chance to match the pre prepared pictures of an aeroplane which is another method of teaching HI children , picture â&#x20AC;&#x201C; matching and it makes a stimuli for the CI child to produce the word . It was observed that they could not pronounce it very clearly at the very beginning mainly due to the fact that the word/ plane/ begins with the initia l /pl/ which they ignored it and pronounced it as /pe:n/ . This is mainly because their tongue is not trained to turn accordingly and this would be the first time they face such an experience in moulding their articulators basically the tongue at this point. Therefore, even the articulators were given some exercises in addition to insisting on production of words to improve the efficacy in language production. These reasons emphasize the importance of a well learned rehabilitator or a speech therapist with regard to the efficacy in L1 acquisition and production rather than keeping a CI child at home which will not benefit the CI child at all in the part of L1 acquisition. When it comes to language production these CI children initially begin with sound production and then the rehabilitators encourage them to produce meaningful words rather than emphasising them to produce only sounds. This makes the children 81

a little bit confused as they have not got the fullest ability to produce the whole word accurately. But still as time goes on they somehow or the other manage to produce the proper word even with several mispronunciations. Being the very first stage of a CI child he or she will depend on the sign language and lip reading which they have been used to. But these acts will not be supportive for a CI child to acquire their L1. Lip reading could be helpful up to some extent as long as it will help the CI child in articulating a specific word appropriately. Other than that they should not get used to sign language and lip reading if they intend to enter mainstream education.

4.4. Language Development and Parental Support

Moreover, some of the researchers have found that unlike mothers, most fathers resist to accept the fact that their child is hearing impaired. 1 This fact is often proven even within this research as most of the mothers were involved in taking care of the CI hearing impaired children, by taking them to rehabilitation programmes, regular clinics and so on. This does not totally prove the fact that fathers of CI children do not involve in making their children normal in hearing at all, but it was visible very often among the sample candidates of this research too. This factor once again affects when it comes to starting the process of CI, when mothers of those HI children fail to make decisions on their own. This situation is more significant in Sri Lanka , mainly due to the social pattern of life, which is more towards father centred, especially with concern to decision making and financially. Apart from this point of view some parents just neglect their childâ&#x20AC;&#x2DC;s hearing impairment due to various misconceptions which prevail in Sri Lanka. For example, they will delay giving proper treatment to these HI children saying that it is basically due to a bad period of time and at the same time they go behind horoscopes in order to give these children proper audition. What so ever, as parents should not delay the age of recognising the disability and at the same time they should take appropriate measures to eradicate this situation in their children.

(jdsde.oxfordjournals.org)

4.5. Social â&#x20AC;&#x201C; Emotional Development of a CI child Some of the children of this sample were congenitally deaf or hard of hearing, while some were of normal hearing although they became hearing impaired later in life due to various reasons. It is normally said that, once a child has acquired the language it is somewhat easy for that child to catch up the language just after a CI. Apart from the attention of language acquisition these children should be observed in so many other perspectives in order to give them a balanced life in the future as they will be intruding in to mainstream education. Therefore, so many other factors which should be considered were found through this research which will benefit the CI children if the parents and caregivers would be informed accordingly. Much evidence suggests that, a child should receive proper auditory input since it makes robust changes in various areas of oneâ&#x20AC;&#x2DC;s life, not only in the normal development of language but also in cognition and behaviour as well. Even after receiving the CI surgery one could easily identify some of the behavioural patterns of those children, which are less likely to be significant in most of the normal hearing children of the same age. Therefore it is proven how these CI children differ from normal hearing children in several perspectives such as delays in the production of oral language, visual attention and behavioural control. Since they are not very much aware of the sounds around them they lack visual attention as well. Nevertheless, their unusual behaviour too occur due to their inability to hear and recognize sounds around them .Thus the mental trauma they undergo is mainly connected with these unusual behaviours which as care givers and parents should be well informed of, rather than being harsh to these CI children if they should be sent to mainstream education.1 The teachers of deaf take much effort to enable these CI children, grasp their first language instead of having a balanced view about the child as to how the child thinks and his or hers emotions. Thereby once again they become aggressive because they are deprived of love and care the other normal hearing children of the same age receive. Therefore although it is true that these CI children should possess a wealth of oral language, they should be given a balanced view about life and behaviour as 1

(http://cdaci.org) 83

well .Otherwise, once they are being sent to main stream education in normal learning atmosphere, they will tend to become misfits of that society due to the unusual behavioural patterns which could create inhibition in all the other activities including usage of oral language. This would create a huge impact within the CI child and his or her parents which sometimes could be irreversible. Therefore, it is far better if these CI children could be trained in every aspect in order to make them independent, informative, attentive

and more than anything the best ways to cope

with others. Apart from their slow grasping ability with comparison to a normal hearing child, they should be trained to think of others and should inculcate morals and ethics which are related to life since most of these children lack empathy towards others, even towards their parents. It is once again debated, as one could raise an argument saying that it is mainly due to the fact that these children are hard of expressing their views and emotions, but still they have empathy towards their family members which once again become unacceptable as most of these CI children tend to be so violent with their mothers especially. Thus these parents also become intolerant with the time expansion. Although this type of violated behaviours could be identified in some CI children, some are totally reserve as they demand a more passive way of living which is once again a problem when it comes to mainstream education, as most of the teachers tend to forget the disability in these CI children and the teachers tend to assume that these children have completely absorbed what is being taught although it is not so. Therefore these CI children should be well trained to adapt the changing society in order to minimise the difficulties and unjust they face in their long run.

4.6. Analysis of Language Acquisition in CI children. This being the focus idea of this thesis it was decided to analyse the abilities of these CI childrenâ&#x20AC;&#x2DC;s L1 acquisition under two different perspectives. Therefore, whatever the findings of this research would be analysed, under auditory- verbal method initially and later on linguistically.

It was observed

that, three months after receiving the implant almost all

the children in the sample showed some improvement in their language perception and were grasping some of the sounds around them. This period could be taken as some what a silent period as the child still does not have the ability of producing sounds. This does not mean that the CI child does not hear anything or the CI is ineffective. This is an initial period marked by decreased vocalizations while taking in new auditory stimuli.1

4.6.1. Auditory â&#x20AC;&#x201C; Verbal Analysis

The following assessment form was very much useful in analyzing L1 acquisition of CI children due to its orderliness. The same way the CI children were investigated for their different language developmental levels. This was also given as a questionnaire among the focus group and the findings were very much equal to language developmental levels of a normal hearing child. Likewise, their audition, language, speech, cognition and communication levels were observed step by step. Although most of the criteria for L1 acquisition in CI children are in English, this specific study would deal with relevant to Sinhala language. In the meantime, it is expected to figure out the similarities and differences in between English language acquisition and Sinhala language acquisition under sound perception as well as under sound production and speech. This once again would bring out a proper way as to how we being Sri Lankans could adapt the international theories of language acquisition in CI children to suit Sinhala language. Therefore, whatever the findings of this research will be analyzed under this criteria at one level, in order to give a general idea as to how a CI child acquire language. Linguistic analysis of language acquisition of these CI children will be done after this.

(http://professionals.cochlearamericas.com)

Questionnaire 02 - Auditory - Verbal Ongoing Assessment Form. AUDITORY – VERBAL ONGOING ASSESSMENT FORM.

Name

DOB.

Hearing loss

Hearing aid or cochlear implant model

Key.

Beginning

Date started A.V.

Inconsistent +

Consistent Expressive Use (Cross

out check) Ling 6 Sound Test: detection & identification m__ u__ a__ i__ sj__ s__ silence__ Distance (12 cm. 50 cm. 1m. 2m.): m__ u__ a__ i__ sh__ s__ Words in phrases: 1. Vowels + syllables differ __

3. Rhyming words__

2. Same consonant, vowels differ__

4. Final consonants only

differ__ Auditory memory: 1__ 2__ 3__ 4__ 5__ items AUDTINON

Identification of consonants by: manner__

songs & rhymes__

Voicing__

auditory attention to

extended Place__

conversations & stories__

Selection by description: closed set – stage1. Sound-word repeated__ 2. Identify by key words__ (always in phrases) 3. Include objects with similar characteristics__ 4. Begin levels 1& 2 in open set Open set- stage 1. Sound-word repeated__

2. Identify by key words__

3. Complex description__

4. Identify by questioning__

Taped instructions and stories__ listening in noise__ overhearing in group conversations__ dates: LANGUAGE

vocabulary

(1st

year

only

and

with

beginner

listener)

comprehension__wds__wds__ wds__wds__ spontaneous wds__wds__ wds__wds__ nouns: sound-word__ subject nouns__ object nouns__ parts of objects__ by description__ plural nouns: irregular__ regular__

use__

verbs: directives__ present progressive__future__past tense__ conditional__ passive__ pronouns: mine__ I__ you__ he__/or she__ they__him__ her__ them__ his__ hers__ theirs__ we__ us__ it__ our__ yours__ myself__ who/whom__ prepositions: up__ down__ in or on__ under__ behind__ beside__ in front__ in/on__ between__ continue with a concept list__ e.g., (Boehm concepts) adjectives and adverbs: beginning vocabulary list__ continue with a concept list__ negatives: no__ not__ don't__ can't__ didn't__ wasn't__ won't__ conjunctions: and__ not the__ either or__ only__ everything but__ neither-nor__ because__ so__ if__ before__ after__ articles: a__ the__ questions: what's that?__ How many?__ what colour?__ where?__ what's happened?__ How many?__ what colour?__ where?__ what's missing?__ who is it?__ why?__ when?__ How?__ auxiliary questions: do__ are__ is__ can__ does__ will__ have__

Examples o spoken language (bracket missing parts of speech in sentences to obtain future targets,)

e.g, Daddy ('s) car no (won't) go.

Date…………………………………………………………………………………… ………. Date Voice quality: 1-5 (1=poor):__ speech intelligibility (1-5): in context__ out of context__ Suprasegmentals: duration: long__ short__ varied__ Intensity: loud__ soft__ varied__ SPEECH

Frequency: high__ low__ varied__ Vowels: u__ a__ o__ x__ i__ A__ a__ E__v__ e__ x__ i__ Vowels alternated: u-a__ a-u__ -i-a__ e_i__ Diphthongs: (ow) au__ (eye) ai__ (aye)ei__ (oy)oi__ Consonants: level 1-P__ b__ m__ h__ w__ Level 2-t__ d__ n__ f__ v__ (sh)__ 3__ r__ (y)j__ Level 3-k__ g__ l__ (ng)n__ s__ z__ (th) __ (th)__ Unreleased plosives: p__ t__ k__ b__ d__ g__ Affricates: (ch)__ʧ (dg)d3__1 Blends: word initial – sequential___________ co formulated _________complex blends________ Word

final-continuant-continuant__

continuant-stop____

stop-

continuant__ stop-stop___

Adapted from Ling.D.(2002). Speech and the hearing impaired child: Theory

and Practice. 2nd Edition. Washington, DC: Alexander Graham Bell Association for the Deaf. 88

Sorting: identical objects__ categories__ by function, shape, colour, number, texture, content, association Go together: real objects__ cards or puzzles__ colours: red__ blue__ green__ yellow__ Rote counting: 1-10__ number concepts: 1-3__ 4-6__ 7-10__ 11-20__ no.

COGNITION

after__ no. before__ No. in-between__ count by two, three__ addition by one__ by twos__ subtraction by one__ create equal sets__ number stories__ Shapes: circle__ square__ star__ triangle__ rectangle__ diamond__ cross__ Textures: soft__ rough__ continue concept list__ Comparisons: same__ different__ doesn't belong__ how alike__ categories and give reasons why__ Sequencing: shapes__ colours__ patterns__ 2-4 pt.story__ events__ tell story__ multiple endings__ Identity of an object__ opposites__ analogies__ inferences__ synonyms__ Double meanings__ simple jokes__ riddles__ idioms__ Has appropriate eye contact__ Practices turn taking__

uses courtesy language: e.g., bye, I'm sorry,

excuse me__ COMMUNICATION

Initiates interactions__

uses questioning__

Initiates conversational topics__ Repair strategies: asks for repetition__

uses appropriate topic

transitions__ verifies partial information__

shares conversational

control asks for clarification__

provides clarification__

maintains topic: 1 turn__ 2 turn__

extends conversation__

advocates to improve S/N ratio__

uses social interaction skills__

This format of the questionnaire is adapted from Judith I. simser@magma.ca

Consultant in Childhood Hearing Loss, Ottawa, Canada. 89

Simser ,

The above information is collected in order to evaluate the auditory-verbal development of CI children. These facts were investigated after activating the CI. Therefore, the CI child is tested under several areas, such as audition, language, speech, cognition and communication. Although these specifications are given with accordance to English language in this assessment form, the collected data was analysed in order to suit Sri Lankan Sinhala speaking CI children. These amendments were made appropriately with regard to L1 acquisition of these CI children. Accordingly, need arose in changing some of the criteria to bridge the gap between some of the components in English language and Sinhala language. For example, it is normally accepted that CI children acquire one syllable words like /tree/ initially. And then only they are capable of producing words with two, three syllables. On the contrary, this is rejected when it comes to Sinhala language due to several reasons. Likewise, these CI children whose L1 is Sinhala find it very difficult to find frequently used one syllable words but instead they try producing words like /gasə/. If not they will have to attempt on producing /gas/ which is one syllable, but it was not successful as these CI children did not show any confidence in producing this.

4.6.1.1. Audition 

Ling 6 sounds When we pay attention to different categories of this analysis audition levels

of these CI children were tested under different aspects. They were basically tested according to their level perception of Ling 6 sounds. The earlier chapter brought out about this in detail. These CI children were tested as to what degree these 6 sounds, (m, u, a, i, sh, and s) were detected and identified. Although this test is totally on perception , the fact that these CI children are inconsistent in perceiving these /s/ and /ʃ/ sounds are quite evidently proven when they are being asked to pick up the proper card consisting that sound. Nevertheless, it was later on even proved when it comes to producing the word /gasə/, These CI children very often pronounced it as /gaθə/. This is mainly because they fail to produce /s/ sound properly at the beginning level of L1 acquisition, mainly because they haven‘t grasped it properly. 90



Words in Phrases This was quite helpful in finding the levels of detection when it comes to

vowels and consonants. These CI children were very much consistent in grasping consonants rather than vowels as they proceed. Nevertheless, their non verbal reactions were very high and positive towards phrases with rhyming words. And they loved to watch children movies and cartoon as they began to perceive language and there they had the tendency to go near the television in order to get somewhat of the story clearly. 

Listening in noise At the very beginning, these CI children did not react to any sound in a noisy

environment but as time goes on with rehabilitation, they were able to figure out the specific sounds from the other noises.

4.6.1.2 Language 

Production of Words When the language ability of CI children was tested, it was under several

categories. Among them as they were tested for their production of words, their vocabulary was basically based on comprehension, contrary to spontaneous word production. Here it was evident that these CI children will answer the therapists or the parents basically in closed ended questions and there even with one to two word utterances. 

Nouns As another point under language, the production of nouns and their positions

were analysed and it was found that these CI children were more consistent in producing the subject rather than the objects. Moreover, these CI children had the ability to name more familiar objects at the beginning but they were unable to specify the parts of them.



Pronouns Specifying on pronouns, they were able to use only one or two pronouns like

/mage:/ (mine) and /ape:/ (ours). 

Prepositions In addition to that, the production of prepositions were grasped at the later

part of L1 acquisition process. There again, they were able to say; /uɖə/ (up), /jatə/ (down), which was limited in number. 

Adjectives and adverbs When it comes to the production of adjectives and adverbs it was quite

significant that these CI children show a tendency of producing adjectives rather than adverbs. For example, they say /loku/ (big). But they are unable to have both the adjective and the relevant noun together at once. Whenever they want to express the idea that something is very big, they will use the same adjective as /loku:/ rather than saying /godak lokuj/. In contrary to that their usage in adverbs was found hardly at the initial level of L1 production but later on they managed to do so. 

Negatives They were quite good at these negatives like /epa:/(refusing),/ᴂʈi/ (enough)

/bᴂ:/ (can‘t). 

Conjunctions This was quite absent in their speech mainly because they did not have the

ability to produce complex sentences at this level. 

Articles When we talk about articles in Sinhala language, no specific set of articles

could be seen but rather they have been included in the singular noun itself. For example, /gɑsə/ (tree), but if you want to say a tree it should be /gɑsɑk/

Likewise, these variations cannot be adapted by these CI children; instead they use to come out with /gɑsə/ at every instance at this level. Once again it should be noted that these CI children tend to come out with this term /gɑsə/, instead of normal spoken term /gɑhɑ/ may be basically due to the approach picture introduction. 

Questions These CI children were unable to ask questions with two three words. But

very rarely it was found them asking questions using only one word like,/kau (who) . But even this was not properly pronounced and easily understood by the listener. But, when it comes to answering questions they were a little bit ahead than in questioning. Their ability in answering close- ended questions was quite consistent with comparison to answering open- ended questions.

4.6.1.3. Speech

While paying attention to the speech ability of these CI children it was very much evident that they lack the quality of it due to the absence of suprasegmental features like frequency, stress, intonation etc. Nevertheless, another significant fact in their language production was substituting other sounds instead of the appropriate sound. Apart from that production of diphthongs was quite good in these CI children. For example; /auwə/ (hot sun) 

Communication Factors which contribute towards good communication were investigated

among these CI children. Therefore, it was found out that most of these CI children tend to look at the other person when talking but it cannot be still specified as eye contact because they look at the others intending to read lips. Nevertheless, when we talk about turn taking as another fact which comes under good communication, it is much visible in CI children since they do not have spontaneous speech, but when it comes to CI elders it is very difficult to train them to adhere to this turn taking in communication. 93



Interaction Interaction is another factor which fulfils communication. But these CI

children do not possess that as they are not good at questioning. Therefore, they will rather come out with the answers in one or two words for the others questions. The above findings of CI children in their early language development consider some of the significant consistencies as well as inconsistencies. Apart from the audio – verbal analysis, the L1 acquisition of CI children were again analysed under language perception and production.

4.6.2. Linguistic analysis

Before analysing the language development of these CI children linguistically, it was thought that it would be better to give a brief description about Sinhala phonetics since the findings of language production are basically based on Sinhala language. A distinguished feature in Sinhala is the presence of five nasal sounds known as half nasal or pre nasalized stops. However, having said that these CI children too demonstrated considerable tendency of producing language using these sounds very frequently in their speech and it was further proven through questionnaires and focus group discussions. Nevertheless, Sinhala language consists of 61 symbols altogether, out of which 18 are vowel symbols , 41 consonant symbols and 2 semi- consonant symbols.1 Consonant modifiers are another significant factor which makes differences in L1 production within CI children in comparison to English speaking CI children. Nevertheless, Sinhala language is considered as a symbolic language.

These

consonant modifiers are known as character additions .They occur in two different forms, as vocalic stokes and non- vocalic strokes. 2

1 2

Trilingual Sinhala – Tamil-English National Web Site of Sri Lanka. Trilingual Sinhala – Tamil-English National Web Site of Sri Lanka.

4.6.2.1. â&#x20AC;&#x201C;Language Perception

Speech perception is the process by which the sounds of language are heard, interpreted and understood. The study of speech perception is closely linked to the fields of phonetics and phonology in linguistics, cognitive psychology and perception in psychology. Research in speech perception seeks to understand how human listeners recognize speech sounds and use this information to understand spoken language.1 Normal infants begin the process of language acquisition by being able to detect very small differences between speech sounds. In contrast pre lingually hearing impaired children lack this, since they are not exposed to language. Nevertheless, even the post lingually hearing impaired children tend to forget the ability of discriminating sounds due to their loss of auditory input even for a shorter period. Although this thesis basically talks about the ability of language production of CI children , it is not the initial step. Instead, these CI children try to perceive the sounds they hear and this was measured as they react according to what the others say and when commands are being given. Although several differences between CI children are evident in language production, basically between different languages it is not much evident in language perception. This is easily found as they do not struggle a lot in perceiving the language as long as the CI child is comfortable with proper audition levels. 2In order to enable these CI children get use to language perception they should be given proper guidance to build their confident in discriminating sounds within noisy environments and they should also be given adequate opportunities to expose themselves to different sounds. The level of sound perception was once again taken into consideration as to see how it has been affected by the factor age at implantation. There it was identified that one could not identify much of a difference in sound perception among the set of X children and the set of Y children since both the groups showed same standards in carrying out orders after a little bit of a gap. Children of set Y tend to show little bit of a lethargic attitude towards obeying commands with comparison to the children of set X. This could be mainly due to the fact that they had been used to 1 2

(http://en.wikipedia.org/wiki/speech_perception) (www.cochlear.au.com)

keeping quiet in a silent world without any noise heard for a longer period than the children of set X. Therefore they need some extra time to adapt themselves to the new situation created and it could also be an extra weight for their brain too with regard to decoding and encoding.

4.6.2.2. Language Production

Irrespective of all the above facts there were similarities in both sets of CI children when it comes to language production which was not normal at times. One could observe several unique qualities in language production and thereby could gain some assumptions as to why these types of abnormal like language production takes place in CI children at the very early stage of language acquisition. Although we come to a conclusion saying that these types of pronunciations are not appropriate for a 3-4 year child, we should not forget that these types of pronunciations are visible within normal hearing infants who try to acquire their language at the very first stages in their lives. Since these CI children too have received their normal hearing after their birth only at this point they too might be passing that stage even though they are much older than the normal hearing children. The following table shows typical average upper age limits of consonant production;

4.6.2.2.1. Phonological Development.

After perceiving some of the sounds the CI child makes confident efforts in making use of his or her comprehension, as one could observe them carrying out several commands given by their parents or caregivers. This would be a positive turning point in a hearing impaired child with a CI, as it signals the others about their auditory ability. With the ability of perception these CI children start producing different sounds with the help of the parents and basically the rehabilitators. The help of the rehabilitator is very much useful at this point as these necessary steps should be taken accordingly and teaching methodology affects a lot here. Initially these CI children tend to produce onomatophic sounds . This is mainly because they are being exposed to natural sounds in the environment 96

at the very beginning of their

audition. These sounds once again are more towards the vowels rather than the consonants. For example if somebody asked a CI child showing a crying baby what is he doing he or she will answer as / ɑ:/ /ɑ:/ denoting the crying sound. But still they are not capable enough to tell the appropriate word /ɑ ənəwɑ:/ (crying). Similarly at this point if a CI child is being asked about a car he or she will tell as /bu:m/ rather than saying car which denotes the sound of a car. Suppose it is a dog the CI child would address it as / buh/ as it is its sound. This is once again with related to onomatopoeia.

Later, between four and six months after the CI these

children show some ability to produce sounds similar to syllables and specially bilabials as in /bɑbɑbɑ:/, /mɑmɑmɑ:/.etc. This could be named as a babbling stage in which the child plays with his voice and articulators1. As the third milestone of language development these CI children receive the understanding

and the use of

sound/

object associations and inflected

utterances. For example , /miəu/ for cat . At the same time /uh/ - / oh/ are used when ever suprasegmentals and early vowel- consonants are highlighted.2 Anyway it was identified that these CI children were unable to produce /s/ or /ʃ/ due to the inability to move the tongue accordingly but they are capable of moving both the lips in order to produce bilabials like /p/ rather than /s/ . One of the children appeared not to follow this sequential development, as this child already has produced abundant syllables before receiving the CI. That is mainly because he had been a post lingually deaf child due to meningitis at the age of four. Therefore this child was able to communicate through several stimulations such as cued speech and lip reading. Although it is identified that CI children perceive language after receiving a CI , initial difference could be visible within them .But later on with much training these CI children too would demonstrate a language growth which would bridge the gap of language age and chronological age.

1 2

((http://professionals.cochlearamericas.com) http://professionals.cochlearamericas.com)

4.6.2.2.2.- Lexical Development.

Then comes the period of using single words and jargon which is mostly used in their day today life. When these CI children produce different words for the first time in their lives just after the surgery, their pronunciation had some kind of similarity among themselves . Accordingly, when they produced the word /nᴂvə/ (ship) they omitted the initial /nᴂ/ sound and substituted the /ᴂ/ vowel sound more often. In the same way their pronunciation of the word /dɑm/ (purple colour) too had the same significance as they omitted the initial /d/ sound and had only /ɑm/ sound. Therefore omitting the initial sound of most of the words was a prevalent characteristic of these CI children with concern to their production of the first language. Another

characteristic of CI children in producing

words , was over

nasalization whether it is necessary or not. For example the word /ɑuə/ (sunny) was pronounced with a nasalized ending rather than making it a fricative ending. When they are being asked about the weather conditions they tend to reply by saying /ɑuə dɑwəsɑk/. But when it comes to a rainy day they pronounce /wᴂssə/ (rainy) with not much of confidence. Another word which these CI children pronounce is /p nɑ:wə/ (comb) ,in a different way. It once again lacks the proper initial pronunciation but rather they tend to pronounce it as /ɑ:nɑ:wə/ It is much of a contradictory issue with regard to the sound production of CI children as they show quite efficient in producing bilabials although they fail to do so here. Nevertheless, there is another contradictory issue when it comes to pronunciation of long sounds like/ɑ:/. But here these CI children pronounce /ɑ:/ sound at the initial position although it is not necessary. The same pattern is repeated when they pronounce the word /nɑlɑ:wə/ ( Whistle). At these occasions they do not pronounce a longer initial sound but rather they omit the initial /n/ and substitute it with the vowel /ɑ/.It was quite prevalent that these

children tend to omit the initial sounds and substitute them with another vowel sound more often. Being more analytical it was observed the way these CI children pronounce /girəvɑ/ (parrot) . They had the tendency of pronouncing it as /ʤirəvɑ/ rather than having the original sound. The same way these CI children tend to produce so many names of their family members because they associate them a lot 98

and they get

the opportunity to produce these words as needs arise in and out within the home environment. Therefore these children produce words like /amma/ (mother), /tɑ:ttɑ/ (father), /nᴂn ɑ/ (aunt), /mɑ:mɑ/(uncle), /ɑ:ʧʧi/(grandmother) , /si:jɑ/ (grandfather) ,/ kkɑ/ (elder sister). Still at the initial stage of L1 production even these words could be produced by the CI children only if they are given some stimuli like pointing at the member and ask who is that? Rather than that it is very rare to see these CI children coming up with these words spontaneously. Apart from the frequency of the usage of these above words, some of The differences in their production were identified. Although it was identified that these CI children were able to produce the names of their family members, they had some unique indifferences among them. When it comes to the word /nᴂndɑ/(aunt) these children pronounced it as /ᴂndɑ/ and it was also visible that they had some difficulty in touching the alveolar ridge with their tongue in order to produce the sound /n/, but still they had the impression that they have to do so. Because of that they tried to raise their tongue a little bit in order to have the maximum effort which later on helped them to pronounce it as a normal hearing child. In the same way it was observed how these CI children produce the word /si:jɑ/(grandfather) just after two-three months of their CI. There once again, it was identified that these CI children pronounced it as /i:ja/ instead of /si:jɑ/. This could be due to the fact which was brought out earlier - their disability to produce sounds like /s/, /ʃ/ etc. Nevertheless it has some connectivity with the inability to move their tongue properly , enabling only a controlled set of air to be sent out in order to get these two sounds /s/ and /ʃ/. The same way their inability towards the same issue was proven once again as they were unable to produce the word /sɑpɑttuə/ (shoe) properly ; instead they produced it as /pɑpɑttuə/. However they did not show any indifference in producing the word /mɑ:m / (uncle) as these children have the ability in producing bilabials using their lips and at the same time this does not need much involvement of the tongue. It was moreover proven that the CI children attempted to produce the word /ɑ:ʧʧi/ (grandmother) to a considerable amount only with a lack of the ending more frequently. Other than that when they produce the words /ɑmmɑ/ (mother) and /tɑ:ttɑ:/ (father) , they were quite sure about those pronunciations with comparison

to the other names of their family members may be mainly due to the fact that they use them frequently. The word /ɑkkɑ/ (elder sister) being produced by a CI child ,too had some unique features as they did not pronounce the final /ɑ:/ vowel sound that much although they keep on opening their mouth for some time . This leads them to pronounce it with a short vowel sound ending rather than having a long vowel sound. Nevertheless these CI children had a tendency in producing the /k/ sound in the middle of the word /ɑkkɑ/ with a mixture of a voiced /g/ sound. Therefore it was more or less sounded as /ɑggə/ within CI children. They were some of the key words which were taken into consideration with regard to the names of the family members and how these CI children explicit their ability in producing them soon after their CI . Apart from the names of the family members, the pronunciation of many more words among the CI children were observed within this research and some of them had been included in this thesis in order to come to a conclusion as to how and what they acquire most in their initial stage of language acquisition. Production of the names of the family members were trained and practised by the parents of these CI children , with the guidance of the rehabilitators. But these CI children have no idea as to what they say in different situations and this was trained specially by a speech therapist or a rehabilitator, as these CI children lack spontaneous speech at the initial stage just after the surgery. Therefore they need guidance to perceive the sounds of specific words and then they should undergo the process of matching those sounds with the appropriate object or the picture. Then only they would be able to respond to any of the commands which occur in their surroundings. Thus at the initial stage guided learning would be advised. Through guided teaching learning process the CI children were able to produce several other words in a sequential order according to their need and use. Thereby

CI children were trained to learn

L1(Sinhala).They

were

basically

the days of the week in their /sɑ udɑ:/,

/ɑ əhɑruwɑ:dɑ:/,

/bɑdɑ:dɑ:/,/brɑhɑspətinda:/,/sikurɑ:dɑ:/, /senəsurɑ:dɑ:/ and /irid :/.(From Monday to Sunday) Although there are seven days here they were able to produce only a few even after a lot of training .Still they were unable to pronounce the final long vowel sound to the maximum. Thereby, it sounded like /sɑ udɑ/ more often . But they had the ability to figure out the specific day by looking at the calendar. At the same time 100

they did not show any disability in producing the nasal sounds in /sɑ udɑ:/ . The tendency of nasalization was quite prevalent among these CI children even with some of the words which did not really need it. Other than /sɑ udɑ/(Monday) they tried their level best to pronounce /iridɑ/.But other than those two days they were not able to pronounce the rest of the days of the week with ease and even though they pronounce it was not clear for somebody to understand. When comparing other words which they were trained to produce were almost related to their day today life . For example /kɑɖe/ (boutique) was another word pronounced by these CI children. At this instance they were unable to produce the initial consonant /k/ but rather they managed to pronounce the rest of it. These CI children were given some kind of stimulus by showing a real boutique or through picture – matching. The same scenario reoccurred when they pronounced the word /kɑhɑ/ (yellow), where they omitted the initial consonant sound /k/ . Another word which was taken into account was /heʈə/ (tomorrow) and it too was identified as mispronounced by these CI children as they had the tendency to pronounce it as /hetə/ . Here they have substituted the sound /t/ instead of /ʈ/.Nevertheless their pronunciation with the initial /h/ even was not clear as they tend to produce a similar voiced sound rather than having the exact glottal /h/. There were some specific words which were used very frequently among the CI students according to their need and whenever they wanted to express something. They were more often /iwərɑi/ (finished), /ᴂʈi/ (enough),/epɑ:/(refusing). As the issue of bilabials was brought out, this would be another supportive factor to prove it . Normally it was visible that these CI children tend to pronounce bilabials very much accurately with comparison to other sounds. Likewise the word /bo:ŋʧi/ (beans) was pronounced with the initial /bo/ sound and the / ʧ/ sound very much accurately but there was an omission in the middle , although they were much familiar with the nasalization. They lack the /ŋ/ sound in between . In contrast , although these CI children are said to be much familiar with the bilabials, they were unable to produce /p/ the voiceless bilabial unlike the voiced bilabial /b/. For example when they pronounced the word /pɑnɑ:wə/(comb) they omitted the sound /p/ and had the rest like /a:nawə/. Another characteristic which was identified through the process of collecting data was the way of producing several names of animals . In this case too most of the children who received the CI within the same period of time showed much similarity 101

in producing words like /pu:tɑ/ instead of /pu:sɑ/ ( cat) and /hɑ; ɑ/ for /hɑ:wɑ/ ( rabbit) .They faced difficulty in producing /w/ sound as they didn‘t have proper practice in changing the places of articulation, specially having contacts with the lower lip and the lower teeth. Instead they produced the more significant nasalized / / sound. In the same manner they produced the word /mɑ:luwɑ/ (fish) as / a uwa/. Even in the production of the word /ᴂʈɑ/ ( tusker elephant) these children had the tendency of having a nasalized sound in the middle of the word ;/ᴂ ɑ/. When they produce the word /hɑrəkɑ/ ( bull) ,they had their own identity as in /ɑwəkɑ/. Nevertheless, these CI children have a tendency to omit the initial /ku/ sound in the word /kukulɑ/ (cockerel) and substitute the relevant vowel sound /u/ instead and have it as /ukulɑ/. Moreover, when it comes to the word /eluwɑ/ (goat) , these CI children pronounce it as /evuwɑ/ , These are some of the findings with relevant to the production in lexis of CI children in their early months after the surgery, but it should not be misled that these speech samples could be found in spontaneous speech rather, they were gathered under stimulations.

4.6.2.2.3. Morphological Development

These CI children produce sufficient amount of language which gives much example under morphology , even they do so unconsciously. When they produce utterances they stick to the Sinhala spoken variety . Therefore, much attention is not given to grammatical accuracy since our main aim is to make these CI children produce somewhat of sensible language by overcoming the inhibition they had had for several years in producing language after their birth. Unlike in the written variety in Sinhala language, the spoken variety does not bring out great prominence towards agreement nor gender. Therefore these CI children can survive without making many errors morphologically in these two aspects. For example , they can just tell /gijɑ/ (went) with male or female irrespective of saying /gijɑ:jə/ for a female and /giye:y / for a male as in written variety . They have not grasped that much of grammar knowledge at this stage due to the lack of auditory exposure, but later on as time spans they grasp those theories appropriately as normal hearing 102

children do. Nevertheless , when

talking of agreement once again with plural

subjects even the spoken variety remains the same in the verb as in /gijɑ/. Therefore these CI children do not want to strain a lot in the production of verbs even with pluralisation in verbs. But when it comes to the noun phrase the morphology is a little bit confusing within these CI children , but it was observed at the initial stages these CI children tend to ignore those pluralisation in noun phrases, rather they produce singular noun phrases more frequently. For example , even they see two dogs at once they say /bɑllɑ/ ( one dog). . However, these CI children tend to use past tense more often rather than using present tense even when it is needed ,sometimes may be due to the ease of pronunciation. For example in words like , /janəwɑ/ (going) they tend to say /giyɑ/(went) although it is not suitable. Therefore the ability to use proper tense was somewhat debated throughout the research but that too was at the very beginning of language acquisition as they grasped all those as time goes on. Nevertheless, their inability to produce bound morphemes was another significant factor at this stage. For example they could not produce /bɑllek/ (a specific dog) but only the word /bɑllɑ/ (dog). When we talk about gender with relevant to the noun or the subject they did not have the capacity to produce the proper word for the cockerel and the hen respectively /kukulɑ/ and /kikili/ ,rather they would say /kukulɑ/ for both. Similarly , even the case is not addressed properly as these CI children do not have a clear idea as to how to put the same noun in different places of a sentence. For example although a normal hearing child of the same age is able to say /ɑmmɑge / (mother‘s) , these CI children lack that ability ,instead they use the word /ɑmmɑ/ (mother) even the necessity arises. Likewise, so many

differences

in the field of morphology could be

identified within the CI children at the initial stage of language acquisition after receiving the cochlear. But it should be once again noted that they pick up all those grammatical issues with regard to their first language later on after about one and half to two years time.

103

4.6.2.2.4. Syntactic Development.

These CI children produce utterances in Sinhala basically since their L1 is Sinhala and therefore they tend to stick to SOV order. But still it was investigated most of these CI children tend to omit the object of the sentence and have only the subject and the verb in order to make their sentence precise. For example , /ɑmmɑ gijɑ/ (mother went) . There you find only the subject(/ɑmmɑ/) and the verb (/gijɑ/) . Unless you ask them they will not tell where she went. They say /mɑmə kᴂ:wɑ/ (I ate ) but do not take any effort to have the object of the sentence . If somebody asks only they will give the answer for it. Syntax of a sentence consists of active and passive voice of a sentence. Therefore, when it comes to the production of active and passive sentences in CI children one could easily come to a conclusion that they do not attempt to produce passive sentences at all. Instead they produce active voice sentences having the idea of conveying their own messages easily. Furthermore,

when we consider the usage of adjectives and adverbs in

Sinhala language among these CI children, it was identified that these children have the ability to use adjectives rather frequently compared to adverbs at the initial stage of language production. For example ,/usə/ (tall),but they hardly use adverbs such as /hɑjjen/ (fast). When we talk about more than one word utterances these CI children easily grasped most of the commands as time goes on. Thereby, these CI children produced utterances like /mɑʈə ɖennə/ (give me). This was earlier produced as /ɖennə/ (give) only. As CI children were not that good at saying possessives in Sinhala ,like /mɑge:/ (mine), they were quite easily able to produce /mɑʈə/. Apart from the above findings their reading and comprehension abilities too were observed . Among those areas these CI children showed considerable amount of improvement . Moreover, even the three year old CI children had the ability to read and understand small words after some time of training, which would be sometimes even a failure among normal hearing children of this age. Therefore ,one could easily decide that there is no doubt about the memory capacity of the brain except for this lack of proper auditory input. Once it is being operated within these CI children we could turn them into the level of normal hearing children with no doubt. 104

According to the above findings in the field of linguistics it is proven that these CI children mainly aim at conveying their inner thoughts as the initial step. For that they make use of several strategies such as speech cues , lip reading and even the sign language up to some extent. Nevertheless , they follow the instructions given by the parents and the teachers until they move on to the mainstream education. After they mix up with normal hearing children, it is found that they are very tactful in grasping the language at a very effective pace basically due to peer pressure.

4.7. Conclusion All the above findings of this research help a person to identify the main abilities and difficulties in L1 acquisition basically, with regard to Sinhala language. Nevertheless, one could easily identify these developmental stages with relevant to their chronological age as well as the implant age. Since this thesis mainly deals with the early developmental stages of L1 acquisition of CI children, much of the language components could not be analysed in depth. But more importantly this research gives somewhat of

a wide knowledge about L1 acquisition and its

significances in CI children. Moreover, this shows the importance of rehabilitation at proper age without making any delay.

105

CHAPTER 5

GENERAL CONCLUSION 5.0- Introduction The present study analyzed the efficacy of language development in hearing impaired, CI children. Similarly, the prominence was given to some of the factors which contribute towards making this implantation successful in the field of L1 acquisition. It was observed how age at implantation, parental support and the rehabilitation process affect towards the efficacy in acquiring L1 within these CI children. However, it should be stressed that none of the above factors would exclusively contribute towards the efficacy of CI in the account of L1 acquisition. Therefore, a linguistic analysis was done to figure out their language development within the range of their ability. Subsequently, the significances of Sinhala language acquisition in a CI child within the early language developmental stages were identified in accordance with the developmental stages of English language acquisition. Thus, this chapter will be based on the summary of main findings and their implications. It would consist how age at cochlear implantation affects hearing impaired CI children and to what extent with the collaborative effort of parents and rehabilitators. It was clearly found that the efficacy of a CI totally depend on these areas apart from a successful surgery. Thus, this would bring out a brief discussion on methodological considerations related to this research and the efficacy of some of the methods in rehabilitating these CI children to acquire their L1. Nevertheless, this thesis brought out some information about cochlear implant as a device and its importance. Moreover, it was also discussed the ways to get a CI and how a candidate is selected. Finally, some of the recommendations which would facilitate future researchers will also be included in this chapter.

106

5.1. About Cochlear Implant This thesis basically dealt with some contributory issues which should be fulfilled simultaneously with a CI surgery. Accordingly, a brief knowledge about the CI was given in chapter two of this thesis. It talks about several factors which would surely give some knowledge to people as it is something new to our country. Although most people are aware of normal hearing aids as a remedy for the hearing impairment, they are not that aware of this. Therefore, if people could be informed about this CI, through this thesis it would be great, especially for infants who are deprived of proper auditory input because they have a long way to go in their lives. Nevertheless, it brought out so many other relevant facts which contribute towards the success of a CI. Among them parents are informed as to how they should handle the device and at the same time how to protect their children. When we talk about the surgery it was also mentioned about preoperative and postoperative factors which go together with the surgery in order to make this CI successful. If not for a successful surgery the HI children will not get proper auditory input in their lives. In addition to these above facts it was also emphasised how a normal person hear and due to what factors do people become hearing impaired.

5.2. Summary of Main Findings The summary of main findings of this research can be categorized under several components as they vary according to the objectives of this thesis. Thereby, firstly the collected data was categorized according to the age factor, parental support and rehabilitation .Then, the retrieved data was investigated as auditory- verbally and linguistically.

5.2.1. Age Factor

One of the core findings of the present dissertation is the clear effect of hearing age in the course of language acquisition among hearing impaired children. It 107

was found that, earlier the HI children receive a CI, easier and faster they acquire language than receiving a CI later in life. Although much evidence was found out to prove the fact that hearing impaired children are being affected to a greater extent with regard to positive and negative results in language acquisition according to the age at implantation, not many significant effects towards language acquisition within CI children were identified due to the cause of becoming hearing impaired or due to the age at becoming hearing impaired. But these two factors sometimes demonstrated rather positive notes as these CI children who were hearing impaired later in life due to some ailment like meningitis, acquired L1 much faster than the HI children who became deaf by birth. Although it was generalized as that, at times there were occasions which contradicted that point when some of the post lingually HI children did not perform a satisfactory development in their language after the CI unlike other CI children. In this case there could be several counter arguments. Thereby, one could argue that none of these CI children come up with unique language output and the other factors which directly change these theories are the effect of parental support and the time constraint of rehabilitation programmes. At the same time, the level of language acquisition of these CI children was considerably better than the other CI children who were trying to grasp language from the scratch. Nevertheless, these CI children who get this impairment post lingually tend to maintain the quality of speech rather than the pre lingually HI, CI children as they almost have all the suprasegmentals included in their speech. Specifically, suprasegmentals mean intensity, duration and frequency within oneâ&#x20AC;&#x2DC;s speech. Basically, it is mostly the stress and intonation patterns in speech. Comparatively, the pre lingually HI, CI children have to struggle a lot in acquiring these suprasegmentals even after acquiring correct language. That is another instance where age at implant affects when it comes to the fact , suprasegmentals. Whenever a HI child receives a CI as early as possible acquires all the suprasegmentals and uses them within language appropriately. Comparatively, whenever a HI child receives a CI later in life lack this quality in speech and it would be more mechanical. But as time goes on they should be made to realise the significances of these supra segmentals and thereby they will adapt them into their language production later in their life although it would not be up to the fullest. Notably, it was found out who ever underwent deprivation of auditory input has to follow the same process of language acquisition. Still, there is a vast difference between the process of language acquisition within HI adults and 108

infants. As this thesis deals with the developmental stages of language acquisition within HI, CI infants the main emphasis would be on finding the phonological, morphological and syntactical significances. Nevertheless, it was identified as to what sounds they produce initially and whether they have some kind of uniformity among other CI children. Moreover, these acquisition levels were somewhat compared with CI children whose L1 is English. But it should be noted that this fact was analysed in a very minor scale and not in depth. Therefore, the basic findings of this thesis analysed how the age at implantation affects a lot in the process of L1 acquisition with regard to so many other linguistic factors connected with language. Although many conclusions were made on several language developmental stages and the language components with the prior findings one should not have the wrong implication that any CI child could reach these levels just because of the implant, which is totally rejected as it was evidently proven that without the proper parental support and rehabilitation this would not become a success.

5.2.1.1. Effects of becoming pre lingually HI and post lingually HI

The findings led to so many implications as to what extent one could figure out the significances of L1 acquisition in accordance with the age at implant and at the same time with relation to the category of impairment, whether it is pre lingual HI or post lingual HI. When talking further about the effects of the cause of becoming hearing impaired one could be either pre lingually HI or post lingually HI. Normally pre lingual hearing impairment occurs due to heredity or any other complications which might have affected during the period of pregnancy. Likewise, post lingual hearing impairment takes place due to several ailments later in life basically due to meningitis.

Although most of the literature reveals that the post lingually hearing

impaired children demonstrate a considerable pace in acquiring language than the pre lingually hearing impaired children it was disapproved at several occasions throughout this research, due to the fact that many of the post lingually HI children even struggled the same way as the pre lingually HI children specially when it comes to language production. Even in the course of language perception these post lingually HI children spent somewhat equal time constrain as pre lingually HI 109

children. Therefore it is debated whether one could solely depend on the fact that, post lingually HI children would acquire language faster and more accurately than pre lingually HI children after receiving a CI. But there were several occasions where the earlier fact of other literature came true, that are post lingually HI children acquiring language easily. Still this cannot be theorized as it was not always prevalent repetitively at similar situations. Apart from this inference it was further observed that even the post lingually HI children who were potent in acquiring language at a higher pace than pre lingually HI children, were to be girls. This implication once again digress the current study but still it is something to be further analysed. Therefore, gender becomes a matter of fact which would enhance the researchers who are interested in investigating the effective factors towards language acquisition.

5.2.2. Parental Support

Although parental support is taken separately it cannot solely contribute towards making this surgery a success, but still this factor plays a major role in this topic as parents are the most responsible in getting down a CI for their HI children. Moreover, it is up to them to diagnose the deficiency even. If it was not diagnosed early then again the HI childâ&#x20AC;&#x2DC;s L1 acquisition delays. However, these parents should involve in making decisions at every level of this L1 acquisition process of these CI children. Thereby, they have to decide on a proper E.N.T. surgeon , audiologist and then therapist. Apart from that they are the ones who have to face the economical problems when finding the cost of this cochlear. Next, even after the surgery they have a great responsibility in engaging in post operative acts and then in rehabilitation activities in daily basis.

5.2.3. Rehabilitation Process

As it was mentioned earlier, although we tend to talk on these effective factors which contribute towards the efficacy of CI separately they cannot occur at different times. Yet, they all should get together simultaneously in order to get the 110

maximum benefits out of a CI in the process of L1 acquisition. Hence, rehabilitation process also should take place immediately after the HI child receiving

a CI.

Nevertheless, the appropriate methods to rehabilitate these CI children were discussed and these CI children were tested for their language development under these methods which gave successful results. Although these methods were very often related to English language, it was managed to analyse adapting necessary changes to suit Sinhala language and Sri Lankan culture.

5.2.4. Language Development

When we consider language development in a HI, CI child it was investigated under different perspectives. Initially, just after the implant they were tested for their auditory perception which was measured under several methods such as, aided audition tests, through several responses to sounds like smiling, head turning etc. Therefore, the first and the foremost task in developing language is to enable these CI children to get proper auditory input and to make them perceive language effectively. After that these CI children were given opportunities to produce language step by step through stimulus response method. Secondly, the language development of these CI children was investigated under two main perspectives. Once the basic findings of L1 acquisition was analysed under auditory â&#x20AC;&#x201C; verbal theory and then analysed linguistically. When it comes to auditory â&#x20AC;&#x201C; verbal theory the L1 acquisition of these CI children were tested under several categories such as audition, language, speech and communication. Then they were linguistically analysed phonologically, morphologically and then syntactically. Therefore, some of the findings had some similarities

in the process of L1

perception , which was basically tested under the standards of Ling 6 sound test. Thereby, it was quite evident irrespective of very minute differences , almost all the CI children detected and responded towards m, u, a and i but they were inconsistent in perceiving /s/ and /Ę&#x192;/ sound. Nevertheless, these CI children had some kind of tendency in omitting the proper sound at specific places, instead substituting other sound according to the ease of production. For example they will very often omit either the initial sound or the final sound. In the same way these CI children grasped consonants easily than 111

vowels. But when it comes to production of words it did not have that kind of clear evidence. Then were tested for their language development and it was tested that these CI children were very confident in producing nouns in the subject position at the very beginning of language development. When we talk about verbs they were very comfortable with past tense verbs although they do not match every situation. Their language development in pronouns and prepositions was very limited as they had two or three of them under each category. Next, when the production of adjectives and adverbs is considered it was found out that these children were able to use some of the adjectives but they hardly used adverbs in their speech. Nevertheless, they were good at answering close-ended questions rather than open-ended question as they do not possess the ability of spontaneous speech and at the same time it was once again identified that their imaginary power is somewhat low when compared to normal hearing children of the same age. Speech within these CI children was also tested with accordance to several factors such as suprasegmentals and diphthongs. Then it was proven that these CI children were not that good at L1 production with suprasegmentals which eventually gave a mechanical effect to their speech .In the contrary, they were really good at producing diphthongs. This was mainly identified when they had a frequently occurring tendency in producing diphthongs whenever they tend to substitute some words. Apart from the above facts, these CI children were also tested for their communication development under several qualities such as, turn taking and interactions which ultimately gave negative results as they did not have spontaneous speech . Afterwards, these CI children were tested

for their L1 acquisition

linguistically. Thereby, their language production was analysed phonologically, morphologically and syntactically. Although it was said that none of these CI children demonstrate unique characteristics in L1 production, some of the similar facts among these CI children could be found towards the end of the research . Similarly, it was identified that the L1 acquisition process of a CI child would be more or less the same as a normal hearing child irrespective of the chronological age. This thesis basically dealt with Sinhala language acquisition within CI children which was at times difficult to analyse as the significant findings were demonstrating 112

contradictory issues in comparison to earlier proven language acquisition theories. For example, English speaking normal children will acquire /ʃ/ sound easily as in /woʃ/, But in Sinhala we hardly find very familiar words with /ʃ/ sound in order to test these CI children‘s ability in producing this sound. Moreover, /f/ is another difficult sound which could not be found very often in Sinhala language although English speaking children are very familiar with the word /fᴂn/. Apart from the differences found phonologically, some other differences were very much evident in other fields of linguistics such as in pragmatics, morphology and even in syntax. Therefore, when we consider pragmatics there are so many immediate examples in English unlike in Sinhala. Thus, these English speaking CI children who try to express their likes and dislikes are encouraged through these pragmatics like wow! ,oh!,no.., which the therapists consider them as normal, meaningful utterances, whereas in Sinhala due to lack of these types of pragmatics the CI children are inhibited to express their views until they become proficient in producing most of the sounds. Otherwise, they will come out with

very few utterances like ah!, etc.

Nevertheless, finding one syllabic words is another barrier in Sinhala language as most of the Sinhala words consist of minimum two syllables. Thus, one could find enough and more one syllabic words in English language like tree, bus etc. But if we try to direct translate and take those word as the initial teaching sources for these CI children, it would not give very good results. Therefore, if we always stick in to the teaching methods which are being stereo typed internationally, basically towards English , it is not that advisable. As revealed through the observations it was so happy to see how our speech therapists adopt the suitable theories, matching suitable examples, not only to match Sinhala language but also to match our culture. Likewise, they use Sinhala pragmatics like /ɑne:/ /ɑjjo:/ which give some kind of negative idea. Nevertheless, these therapists use vocabulary connected with day today life even they consist many syllables at times. When these CI children come across several objects very often they tend to produce it irrespective of its length. For example, there were instances when CI children pronounce the word /bo:ʈələjə/ easily although it is a lengthy word for them . This is mainly because they come across this object very often.

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5.3 Future Research Problems The data for this specific research was collected only within a fairly short period of time, comparing to other researches. Consequently, the initial language development of these CI children was observed as they were just after the surgery. Yet, it is proposed that it could be continued to do the same findings with much more depth in the light of language acquisition with relevant to CI children. Here the core should be more towards analysing the linguistic components and the sequential order of acquiring them by these CI children. Subsequently, it would allow figuring out the potentiality in acquiring L1 with appropriate to the chronological age factor. Furthermore, this would be supportive in deducing a theory for L1 acquisition in CI children in accordance with the chronological age and language age. This would really take a considerable time period in order to retrieve proper data as time goes on. Nevertheless, if this research could be continued , one could extend the sphere of this study which would enable to study towards linguistic perspective in depth. Despite considering the above facts it would be very much interesting to infer how skilful these CI children in acquiring the grammar components of L1 which was hindered at this level since these CI children were totally emphasising on developing their lexicon. In addition, language acquisition of CI adults too could be taken as a research topic and further it could also be compared with language acquisition of CI children as to find out the significant similarities and differences.

5.4. Conclusion Therefore, it was quite evident that HI, CI children definitely need proper guidance from parents and therapists in order to acquire L1 in proper manner. This is once again supported by the fact that age at implant should be very early, to get the maximum benefits of a CI. All these above mentioned factors should be fulfilled apart from a successful surgery to gain rapid development in L1 within these CI children. Nevertheless, they could be trained with the help of standard language developmental stages. Anyway, the ultimate goal of the collaboration of all the above

114

factors should focus on

sending the HI children to mainstream education and

through that to make them feel equal as other normal children among the society.

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APPENDIX 1 PICTURES Picture 2.1 - Hearing Process

Picture 2.2 - Parts of a CI

Picture 2.3 - Parts of a Cochlear

Picture 3.1 - Rehabilitation material

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APPENDIX 2 QUESTIONAIRES Questionnaire 01 - Acquisition of Ling-6 sounds

Questionnaire 02 - Auditory - Verbal Ongoing Assessment Form

Questionnaire 03 - A study to examine the efficacy of Language Acquisition in CI children with hearing Impairment Questionnaire 04 - Acquisition of Ling-6 sounds

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Questionnaire 03 - A study to examine the efficacy of Language Acquisition in CI children with hearing Impairment A study to examine the efficacy of Language Acquisition in CI children with hearing Impairment.

A research is being conducted on the above topic as fulfillment of the M.A. in Linguistic. Your Kind cooperation in filling this questionnaire with true information is appreciated. All information

that Yon are providing here will be treated as

confidential. Section ‘A’ personal Details Please underline or write the answers 1.

Hospital or institution you are attached to -

The type of work yon do under your job category

Experience in this field.

Highest Educational Qualification -

Professional Qualities if any Section ‘B’

Problems found in CI children with relevance to L1 acquisition.

Tick the language acquisition difficulties that you have come across among the CI children. You are also invited to add any more difficulties not listed below.

Difficulties a)

L1 perception problems

Comprehension problems

Reading problems

Language production problems

Grammatical errors (tenses, articles, preposition etc.)

SOV order violated (whether there are any omissions & substitutions)

Difficulty in spontaneous speech -

Others

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Out of the above list mention the 3 most common difficulties. 1. 2. 3.

Please tick the relevant box on the following table which gives a list of difficulties you face when you train a CI child in L1 acquisition.

Difficulty

Extremely

Difficult

Neutral

Slightly

Not

Difficult

Making them attentive to what you say

Response to different sounds in a noisy environment

Producing voiced sounds

Producing voiceless sounds Section â&#x20AC;&#x2DC;Câ&#x20AC;&#x2122;

Improving L1 acquisition CI children. 9.

Please answer the following questions and complete the table.

What strategies do you adopt in relation to CI children, in dealing with their L1?

Are you satisfied with the results of your reaction? Why / why not?

Difficulties Strategies adopted by you. a)

Satisfied with the results of your reactions (underline) - Extremely satisfied - Satisfied - Neutral - Slightly satisfied - Not

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Why/why not

10.

Why do you think CI children have these problems? (Tick)

Poor parental support

Due to age at implant

Lack of rehabilitation

Poor economy status

Outmoded education system in relation to teaching HI children

Other reasons (please specify)

11.

What do you suggest (in relation to teaching methods) to develop L1 acquisition within CI children?

12.

In your opinion, what alterations should be introduced to the system including the curriculum in improving L1 acquisition in CI children.

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Questionnaire 04 - Acquisition of Ling-6 sounds Questionnaire This questionnaire basically deals with the acquisition of Ling-6 Sounds. This is a quick and easy way to record your child‘s listening status and progress. Unlike other questionnaires this includes the name of the CI child because it could benefit the child to get appropriate therapy from therapists and audiologists. Recording the distance a sound is tested at: Start at a distance on 20cm. As the child successfully detects the Ling-6 sounds, increase the distance between sound and the child‘s microphone. Through this type of testing it was found out that these CI children start hearing at a typical speaking voice which is 50-65dB. A typical conversation would be identified by these CI children within a distance of 3 metres. This method of testing the hearing level with accordance to the distance made easy to track the progress of their listening levels. Example: Distance tested at :..................... Presentation Level: Recording the listening situation: These CI children were exposed to listen at several environments such as in a quiet environment at the beginning and later on with distractions like the TV. These CI children were tested like this till they consistently repeats each sound correctly at a range of different distances. Then the records were:Noisy situation OR Quiet situation Completing the check table: The child‘s responses to each following sound were tested in this. √ = Correct response — = no response Example ah Monday Tuesday Wednesday Thursday Friday Saturday Sunday

m √ √ √ √ √ √ √

oo √ √ √ √ √ √ √

sh √ √ √ √ √ √ √

s √ √ √ -

ee -

√ √ √ √ √ √ √

Interpreting the above results: This gives an overview of the beginning of L1 acquisition in CI children. Thereby it was evident that; /ah/ , /m/,/u:/ and /i:/ sounds were detected consistently and correctly. But when it comes to /ʃ/ it did not give constant results. Nevertheless, very frequently these children were incompetent in detecting /s/ sound at all. 121

This gives a clear implication that a CI child in the early stages, acquiring speech sounds takes a little more time to become accustomed to /s/ and /Ę&#x192;/ sounds rather than the other Ling sounds. Through this type of daily checking, ability of language perception and its development was investigated.

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APPENDIX 3 VIDEO CLIPS VCD No.01 

Vi deo Clip No. 1 - Parts of the ear



Vi deo Clip No. 2 - Hearing Process



Vi deo Clip No. 3 - Parts of a CI



Vi deo Clip No. 4 - LLT1.f4V - Speech Therapy

CI surgery - DVD No. 1

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Universal Newborn Hearing Screening and Early Identification of Deafness: Parents' Responses to Knowing Early and Their Expectations of Child Communication Development 

Oxford Journals

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Medicine

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Jnl. of Deaf Studies and Deaf Education

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Volume12, Issue2

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