Of every 1,000 infants born in the United States, one to three have bilateral hearing loss, which has the potential to impact language development (CDC, 2015). Despite advances in early diagnosis and intervention and hearing technology (i.e., digital hearing aids, cochlear implants), many children who are deaf/hard-of-hearing (D/HH) continue to fall short of achieving appropriate language levels. Compared with their hearing peers, many children who are D/HH develop vocabulary more slowly and struggle with abstract words (e.g., before, after), function words (e.g., the, an), and words with multiple meanings (ASHA. 2010; J Deaf Stud Deaf Educ. 2016:21(2):107). As a result, a high proportion (>40%) of young children who are D/HH have significant gaps in language (J Dev Behav Pediatr. 2017 Sep 19). Thus, many families of children who are D/HH seek to improve spoken language through therapeutic interventions.
Hearing loss, pediatric health
Augmentative and alternative communication (AAC) is an evidence-based approach that targets core communication deficits in children with complex communication needs (J Speech Lang Hear Res. 2010:53(2):350). Language interventions that employ AAC are effective in improving functional expressive and receptive language growth in many heterogeneous populations (Augment Altern Commun. 2007:23(3):204). AAC has been shown to aid speech production abilities in young children with developmental delays (J Speech Lang Hear Res. 2010). In fact, a systematic analysis provides substantial support that early AAC intervention enhances a child's communication and language development (Augment Altern Commun. 2015:31(3):181).
AAC technology is unique in that it is dynamic in nature, provides visual support for abstract linguistic concepts, and offers grammatically appropriate options of what can be said next. It offers voice output for each selection or message, serving as a consistent model for verbalizations and giving the learner a mode of feedback for self-monitoring expression.
In addition to being an effective strategy for children with complex communication needs, these AAC components are also appropriate for a child who misses out on key aspects of language due to hearing loss. AAC applications are now available on iPads, which can be utilized as portable therapy tools that don't require internet access. Considering the broad uptake of iPad technology and the evidence suggesting the positive impact of AAC on language development even among children with normal hearing, applying this approach to support the language gaps so often found in children who are D/HH holds promise.
Despite the demonstrated benefits of AAC in enhancing language development, far too little research exists on the use of AAC among children who are D/HH. Much of the work in AAC and D/HH focuses on children with developmental complexities. Improvements in vocabulary words, self-correcting language, and expressive communication have been reported in more complex populations of D/HH (Communication Disorders Quarterly. 2009:31(1):53). However, most of the models incorporated AAC devices that were relatively simplistic, serving only one communication function. Based on this work and our own data, implementing technology-based AAC intervention with children who are D/HH is an appropriate next step. Building evidence to support AAC as a primary strategy rather than a last resort is critical to ameliorating language gaps experienced by children who are D/HH.
In one intervention study, we tested the feasibility and efficacy of a technology-assisted language intervention (TALI) that incorporated AAC into speech-language therapy for children with bilateral hearing loss and identified gaps in language levels (Disabil Rehabil Assist Technol. 2017 Nov;12(8):808). TouchChat with WordPower was loaded onto an iPad mini, and children aged 4-12 years old with a range of cognitive abilities participated in a structured language intervention utilizing this program as a tool to target and support verbal language skills. The TALI included 12 therapy intervention sessions across 24 weeks. Families chose an auditory-oral approach for children who participated in our study, and all children had either cochlear implants or hearing aids. The goal of the intervention was to improve language skills using the iPad with TouchChat WordPower to directly teach language structures and provide a model for more complex verbal language during therapy sessions. Goals for each child were personalized to his or her needs by the speech-language pathologist, and the level of complexity of the language program was set to match the child's profile. Throughout the intervention, language samples were taken at various time-points to track progress. Primary outcome measures came from language sample analysis and focused on expressive language measures. These included the mean length of utterance (MLUm) in morphemes (calculated by dividing the total number of morphemes the child used by the total number of utterances), number of different words (NDW) spoken in 50 utterances, and the mean turn length (MTL; calculated by dividing the number of child utterances by the number of turns taken by the child). The participants also received pre- and post- intervention evaluations via standardized language assessments and parents filled out a form to assess pragmatic language skills.
Results of the first five participants who completed the TALI were previously published (Disabil Rehabil Assist Technol. 2017). Results of our pilot study indicated that the average MLUm, NDW, and MTL significantly increased between the first and final visit. Among the nine children with language gaps, the average MLUm increased by 75 percent (Fig. 1) between the first and final study visit at 24 weeks (new unpublished data). Additionally, the NDW increased by 70 percent, and the MTL increased by 60 percent. Clinically significant improvements were also seen in expressive and/or receptive language standard scores, indicating that children were closing the language gap. Finally, pragmatic skills improved, as reported by parents who completed the Pragmatic Checklist (Semin Speech Lang. 2012:33(4):297).
Participants significantly increased the number of items they mastered on the checklist as well as the complexity in which they were able to display pragmatic skills (Fig. 2). All children were able to use an AAC device to support and develop effective expressive communication skills, irrespective of their level of cognitive ability. Families received exit interviews that incorporated questions about the triumphs and challenges experienced in their TALI participation. Families reported seeing increased quality and quantity of verbalizations in the children, as well as an ease and enjoyment in using the iPad. Barriers included prioritizing time to use the TALI at home and implementing the intervention in school due to a lack of knowledge/resources.
Efforts should be made to incorporate innovative strategies into traditional speech-language therapy to address persistent language deficits among children who are D/HH, regardless of their cognitive and developmental complexities. Previous intervention studies have included small sample sizes and have not examined the potential of using AAC strategies to target verbal language skills improvement. This pilot study illustrates the potential positive outcomes of this innovative approach. Incorporating AAC technology via iPads into language intervention shows promise in supporting the rapid growth of language among elementary school-age children who are D/HH and exhibit language underperformance. One major benefit of this intervention is that it can be personalized and tailored to the individual needs of each child. Noting the complexity of language acquisition, which includes building vocabulary, grammar, and social language skills, AAC interventions can be structured to systematically build these foundational underpinnings for effective communication development.
Finally, to ensure the continuous exploration of AAC, a randomized trial has been implemented to compare the TALI with traditional therapeutic strategies and better understand its effectiveness in developing language and social skills.
Jareen Meinzen-Derr, PhD
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