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The development of communication and language in deaf preschool children with cochlear implants
International Journal of Pediatric Otorhinolaryngology 41 (1997) 263 – 272
The development of communication and language in deaf preschool children with cochlear implants Gunilla Preisler a,*, Margareta Ahlstro¨m a, Anna-Lena Tvingstedt b b
a Department of Psychology, Uni6ersity of Stockholm, 106 91 Stockholm, Sweden Department of Education and Psychological Research, Malmo¨ School of Education, Post Box 23 501, 200 45 Malmo¨, Sweden
Received 13 February 1997; received in revised form 23 June 1997; accepted 29 June 1997
Abstract The study is an ongoing longitudinal and qualitative psycho-social study of the communicative development in 19 preschool children with cochlear implants, using sign language. The children are video-recorded in natural interactional settings. Analysis of patterns of communication show that 16 of the children use sign language in communication with adults and peers. With regard to oral communication, 13 children were observed to utter single words or speech-like sounds upon an adult’s request, but seldom used spoken words spontaneously. Six children used single spoken words in dialogues with adults if the content of the dialogue was about the here and now, and if the topic of reference was clear. None of the children in the study were able to take part in age-adequate play activities with peers when speech was used in communication. The results are discussed in reference to early mother–infant interaction, the development of communication and language, and the significance of early close relationships for children’s social and emotional development. © 1997 Elsevier Science Ireland Ltd. Keywords: Psycho-social study; Preschool children; Cochlear implants; Mother – infant interaction
* Corresponding author. 0165-5876/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 0 8 7 - 6
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G. Preisler et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 263–272
1. Introduction Language learning or language acquistion is about understanding a world of symbols; that something can be represented by something else, that a word or a gesture can represent an object, an event or an idea. Language is a representation of representations [1]. A large part of the discussion about language development in deaf children with cochlear implants (CI) has been about speech perception and speech production. But speech is not synonymous with language. Perceiving or recognizing spoken words and producing or imitating spoken words or sentences does not amount to commanding a language or understanding the symbolic meaning of a particular word or phrase. Language is not an object or a skill which exists outside the child. Rather it is a mode of action into which the child grows because the mode is implicit in the human developmental system [2]. Which are then the developmental growth paths that lead to language? The most common approach to answering this question has, for a long time, been to search for the roots of spoken language in the development of the auditory and vocal modalities and the roots of sign language in the development of the visual-gestual modality. But the most significant things that the infant needs to learn about language from a developmentally point of view are written on the face, body, voice and gesture of those who talk [3]. The primary contribution of the face to communication is that it reveals the emotional state of the speaker as well as the attitude of the speaker towards the listener. Infants are already from birth attracted to the face, particularly the eyes of the caregiver [4]. This is adaptive as the eyes are vital components in the human signalling system implying emotions and social intentions. Shared gaze between infants and mothers contributes to the establishment of object reference [5]. Infants look at their mothers’ eye gaze and head orientation as if they were attempting to find out what she might be thinking about [3]. Infants tend to follow an adult’s line of regard as early as 2–4 months, but more consistently so by 8 – 10 months of age. This enables the infants to appreciate an important concept: the object of the mother’s attention. This might be one of the more important conceptual precursors to lexical acquisition. Mothers also spend a great deal of time looking at the things to which their infants attend. The activity of the face, particularly the movements of the eyes, also conveys some indexical information [3]. Preverbal abilities in children like the use of conventional gestures, such as pointings and showing, symbolic and combinatorial play, imitation and the use of tools are important predictors of language development [6]. The sharing of meaning in joyful interactions and early mutual play with turn-taking qualities are crucial prerequisites for language development [7]. The interdependence of the spoken language and visual cues can be shown in studies of blind children. One problem for blind children is to acquire spoken language. The early language development in blind children is often delayed, some do not speak for several years, in spite of perfect hearing ability [8,9]. This is probably due to the fact that blind children do not use conventional gestures, it is not possible for them to follow the parent’s
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direction of gaze, or perceive visually emotional cues from the face of their caregiver, and they do not engage in pretend play until a much later age than a sighted child [8]. The significance of early close relationships for children’s social and emotional development has long been recognized [10]. Relationships are viewed as the context in which socialisation takes place and basic competencies emerge [11] in which communicational skills are acquired [12], and in which the regulation of emotions develops [13]. But studies in child development have also shown how children acquire important developmental skills as a result of peer interactions [14]. Delays in expressive language abilities affects the development of social skills, which in turn can hinder children from becoming involved in more complex forms of peer interaction [15]. The ability to use language as a media for sharing experiences and feelings, for referring to abstract concepts, and for relating to future and past experiences, enables a child to become involved in fantasy and role play. If preschool children are to be able to take part in fantasy play, it is important that they are also given the opportunity to develop close friendships with other children. The importance of providing children with specific difficulties the possibilities to acquire language is stressed [16]. Failure to do so not only has consequences for their language development per se, but also for their emotional, social and cognitive development. The idea that one sign system hinders the development of an other, that is still sometimes held, is by no means valid. Studies from the two last decades in particular, have clearly shown the positive effects of sign language learning in deaf children, not only for communicative, social and emotional development but also for language learning in general [12,17–19]. The current debate in Sweden concerns the choice of language to be used with the moderately to severely hard-of-hearing children. It has not been self-evident to parents and teachers to use sign language with a child who, equipped with a hearing aid, can perceive auditory information and develop spoken language. However, the communicative difficulties these children encounter in interaction with peers, and in larger groups are well recognised by the hard of hearing and by their parents and teachers. As a consequence, many parents now choose to let their hard-of-hearing child attend preschool and primary school education together with deaf children [20].
2. A study of children with cochlear implants In 1981, sign language was declared the official language of the deaf in Sweden. It has now been declared that schools for the deaf must ensure children a development towards bilingualism in Swedish Sign Language and Swedish, mainly in its written form. Today there is an offical consensus that, for a child to be considered a CI-candidate, the family must have an established sign language communication with their child. The child is regarded as a deaf child before implantation as well as after. In Sweden, as in most countries, there is a debate about the ethical aspects of implantation, as well as about how to support the
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families and how to give the children appropriate language stimulation. As the situation is quite different from that of most other countries, with regard to the official attitude to the use of sign language, it was found that most research from other countries was of little value as the majority of CI programs are concerned with giving the child a strictly oral education. Therefore, the National Board of Health and Welfare supported a psycho-social follow-up study of CI children using sign language in Sweden which started in 1995 [21].
2.1. The objecti6e of the study One of the objectives of the psycho-social study is to describe the children’s communicative development and the communicative styles of parents and teachers. The means of communication which are used by the children and adults in different contexts are questions of interest here. The study is one in a series of developmental studies concerning deaf and hard-of-hearing children [12,17–20,22,23] as well as children with functional disabilities like blindness and deafblindness [8,9,24].
2.2. Method The study is longitudinal and qualitative. The children are observed every third month by means of video recordings in natural interactional settings with their parents and siblings, and in their preschool settings with teachers and peers. Direct observations and interviews with parents and teachers about the communicative aspects of the development of the children are also made.
2.3. Description of the children The study consists of all the children born betweeen 19901 and 1994, who received implants before the summer of 1996. Today, 19 children participate in the study. The age and sex of the children are presented in Table 1. A further four children who have recently received their implants, are now about to be visited. The children belong to a total population of 27 children. Of the four children who are not taking part in our study, there is one not using the implant, Table 1 The age and sex of the children in the study Age/Sex
3:0–3:11
4:0–4:11
5:0 – 5:11
6:0 – 6:11
Total:
Girls Boys
2 2
1 1
4 3
3 3
10 9
Total
4
2
7
6
19
1
There is one exception: one child was born during the last days of 1989.
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Table 2 Etiology Etiology
Number of subjects
Meningitis Heriditary deafness Progressive hearing loss
6 9 4
Total
19
in one case the parents consider that too many people already are involved. Contact with the two remaining families has not been established. The families are informed about the research project by the two CI teams and, if they declare that they are willing to participate in the study, they are contacted by us. Nine of the children were born deaf. Six had suffered from meningitis (four of them were reported deaf before the age of 13 months, and the others at ages 2 and 5 respectively). The remaining four children had suffered a progressive hearing loss and had become totally deaf when they were between 2 and 4 years old (See Table 2). The children were between 1:11 and 5:4 years old when they were operated (See Table 3). They started to use the implant approximately a month later, with a mean age of 3:8 years (3:10 for the boys and 3:6 for the girls). The children were first approached when they had used their Nucleus 22 Channel implant between 2 weeks and almost 2 years. Today, (November 1996) they have been using their implants between 4 months and 3 years. The average length of use is 20 months, 18 for the boys and 21 for the girls. All of the childrens’ parents are hearing. Of the 19 children, 15 had already started at special preschools for the deaf and hard-of-hearing before a discussion of implantation was raised. For the remaning four children, there were no other preschool alternatives within a reasonable geographical distance other than a preschool for hearing children, hence this preschool form was chosen. Today, in the fall of 1996, two of the oldest children have started school. One child, born deaf, is attending a school for the deaf, and the other, deaf at the age of 3 years and 6 months, is attending a school for hearing children, accompanied by a signing assistant, 13 of the children attend preschools where sign language is the Table 3 Age of deafness and age at the time of operation Age at operation/ Age of deafness
1:11 – 2:11
3:0 – 3:11
4:0 – 4:11
5:0 – 5:11
Total
Deaf before the age of 2 Deaf after the age of 2
5 —
3 2
4 2
1 2
13 6
Total
5
5
6
3
19
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Table 4 Current preschool and school placement of the children in the study The child is attending:
Number of subjects
(1) Special school for the deaf (2) Mainstreamed with hearing children acc. by a personal assistant (3) Special preschool for the deaf (4) Preschool with group-integrated hard of hearing children (5) Preschool for hearing children acc. by a personal assistant (6) Part time in a preschool for deaf children, part time in a preschool for hearing children
1 1 11 2 2 2
main language. Two of them have also started to attend an ordinary preschool setting with hearing children two days a week. Two children are in preschools with group integrated hard-of-hearing children and another two are in a preschool setting with only hearing children (see Table 4). These children have signing assistants. 3. Results After the first year of video observations and interviews with parents and teachers, the analysis showed that 16 of the 19 children were able to use sign language in interaction with parents, teachers and other adults, as well as with signing peers. They discussed present, past and future events, and the majority of these children (14 of 16) took part in fantasy play. Three children were still learning sign langauge because of late diagnosis of deafness or because they had not had access to a signing environment. As a consequence they still had difficulties in participating in linguistic communication with adults and with other children. Six children (five of which became deaf between the age of two and four, and one was born deaf), were observed to perceive single spoken words in dialogues with their parents or teachers if the content of the dialogues was about the here and now, and if the topic of reference was clear. These children had been using their implants for between 1 and almost 3 years, with a mean duration of 2:8 years. In the above mentioned contexts, the children were occassionally able to respond adequately to questions or comments, either with single spoken words or with lip movements corresponding to spoken words. They were further observed to respond with sign language sentences mixed with one or two spoken words. One of the children used spoken sentences with adults, but depended on sign language in order to understand the meaning of the message. As the adults had difficulities in understanding the child’s spoken language, the child’s articulation was poor, and as the child had just recently started learning sign language, there were considerable problems, both with respect to oral and signed dialogues. Misunderstandings occured frequently and both the child and the adults needed repeated clarifications in order to fully understand each other.
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The other 13 children were observed to utter single words or speech-like sounds upon their parent’s request, but they seldom used spoken words spontaneously. None of the nineteen children were able to take part in ‘age- adequate’ oral dialogues, communicate orally in group settings, or take part in ‘age-adequate’ play activities with hearing or hard-of-hearing peers when speech was used in communication. Soon after implantation all of the children in the study were observed by parents and teachers to react to environmental sounds like church bells, airplanes, telephone and door bells as well as to other children shouting or calling from the room nextdoor. Most of them were observed to react when adults were calling for them from a distance. Parents and teachers reported that all of the children vocalised more since they started to use their implants. The children received special training by a special teacher for the hearing impaired or a speech therapist. Half an hour twice a week was the most common model used. This special training was aimed at making the children attentive to sounds and to discriminate between different environmental sounds as well as speech sounds. In these adult-centered, speech oriented and often very well structured communicative contexts, practically all of the children in the study made efforts to utter spoken words or wordlike sounds. The words were mainly the names of persons or of objects, like ‘Mummy’ and ‘Apple’. However, it was observed in these training sessions that some of the teachers tended to overestimate the children’s ability to perceive sounds, in particular speech sounds, but also environmental sounds played from an audiorecorder. In these cases, the children often showed difficulty in understanding the teacher’s intentions, the meaning of the interaction and even the meaningfulness of the situation. On the other hand, there was a tendency to underestimate the children’s cognitive development. The content of the interaction in these training sessions was often considerably below the children’s intellectual level. For a 4- or 5-year old child who can discuss complex phenomena in the future or the past, it can hardly be stimulating to imitate the sound of a cat or a cow, i.e be treated as a 1–2 year old child. What can also observe from the video recordings—there are today (November, 1996) on average four video recordings of each child—that when demands were put upon the children by teachers or parents to produce speech or speech sounds, the children tended to show aversive or oppositional behaviors. The greater the demands from the adult, the less was the response from the child. They looked elsewhere, looked bewildered, or they looked into the camera, and they even yawned. In the interviews with the parents satisfaction was expressed with regard to the CI-operation and they felt that they had done what was within their power to give their child opportunities to perceive sounds. The majority of the parents were convinced that sign language was of utmost importance for their child’s well-being, enabling them to communicate with peers, parents and teachers. But all of them nourished a hope that someday in the future, their children would be able to communicate with speech, at least to some extent. This would enable their children to take part both in the deaf society and also in the world of the hearing.
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4. Discussion If we compare the first results from our ongoing study of the CI children using sign language with results of international studies of orally raised deaf CI children, we find some common traits: all of the children perceive environmental sounds, and most of them perceive and produce a limited set of spoken words/sentences in well defined contexts. The children who use sign language and attend preschools with deaf children, command a language that enables them to take part in the world around them, to join in and interact with others, and share meanings and ideas with adults and peers. They also receive training from a special teacher for the hearing impaired or speech therapist. These sessions are now under discussion with the aim of improving the possibility of the children to detect and discuss sounds, and to use speech in natural interactional settings depending on their personal ability. The situation of the CI children in preschools/schools where speech is the main language, gives cause for apprehension. Their opportunities to take part in dialogues with peers are limited, they interact mostly with signing adults, and adults often take the role of interpreter for both other adults and children. The importance of play and relations to peers has been emphasised by many researchers. What are the consequences for a child who has an adult functioning as a mediator? It does not promote friendship, as normal peer relations become impossible. The dialogue with other persons is of great importance for the child’s development. In these encounters, the child forms inner models for future encounters and relations. What inner model for encounters and relations will these children form? The view held today is that the child acquires language in natural interactional settings. A number of studies [25 –28] have shown the advantages of using incidental teaching in comparison to traditional language training methods. Other studies have shown that children often react negatively to questions posed by adults which they perceive as inquiries [29]. But questions posed by adults with a clear intention of getting to know the children’s opinions, ideas or views, elicit many more responses from the children [30]. The possibilities for the child to engage in meaningful interaction is to a great extent dependent on the ability of an adult to adapt to a child and to give space for the child to take an active part in the interaction — to follow rather than direct the child. If we regard the children as passive receivers of information, the children might gradually develop a sense of self as passive, or even incompetent and disabled. This will have severe consequences for the child’s social, emotional, communicative and cognitive development. For approximately 20 years now, deaf children in Sweden have been raised as normal children. They have acquired language spontaneously, as hearing children do. They have become bilingual by means of sign language and written Swedish. They have developed a sense of identity as a cultural minority, not as a group of disabled. Their academic achievements are now almost in parity with those of hearing children [19]. In studies of deaf children with cochlear implants, fundamental knowledge based on the latest findings from the field of child development in general, and language development in particular, are seldom or never discussed. The CI children are deaf children. Without the implant they are as deaf as before
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the operation. Even if they will be able to perceive speech and to express themselves orally when using the implant, they will still be socially deaf in the same way as is reported among even moderately hard-of-hearing children [20,22,23]. If we can enable them to become bilingual—in sign language as well as in reading and writing - and to gradually also be able to use speech, then the implant can become something positive, an extra asset for them. But if we solely rely on their ability to take part in social interaction by means of auditory perception through the implant, their future emotional, social and also cognitive development will be at risk.
References [1] J. Piaget, Play, Dreams and Imitation in Childhood. Heinemann, London, 1951. [2] M. Studdert-Kennedy, Language development from an evolutionary perspective, in: N. Krasnegor, D. Rumbaugh, R. Schiefelbusch, M. Studdert-Kennedy (Eds.), Language acquisition: Biological and behavioral determinants. Lawrence Erlbaum, Hillsdale, 1991. [3] J. Locke, Development of the capacity for spoken language, in: P. Fletcher, B. MacWhinney (Eds.), The Handbook of Child Language, Blackwell, Oxford, 1995. [4] T.G.R. Bower, A primer of infant development, Freeman, San Fransisco, 1977. [5] J. Bruner, The ontogenesis of speech acts, J. Child Language 2 (1975) 1 – 19. [6] E. Bates, L. Benigni, I. Bretherton, L. Camaioni, V. Volterra, Cognition and communication from nine to thirteen months, in: E. Bates (Ed.), The Emergence of Symbols: Cognition and Communication in Infancy, Academic Press, New York, 1979, pp. 69 – 140. [7] C. Trevarthen, Infants trying to talk, in: R. So¨derbergh (Ed.), Children’s Creative Communication. Lund University Press, Lund, 1988, pp. 9 – 31. [8] G. Preisler, The development of communication in blind and in deaf infants — similarities and differences, Child: Care Health Dev. 21 (2) (1995) 79 – 110. [9] G. Preisler, The consequences of sensory and multiple impairments on early communicative development between mother and child. In: The development of communication. What is new? Communication and Congenital Deafblindness. Actes du Cours International, Suresnes, 23 – 26 June 1996. E´ditions du Centre National de Suresnes, 58 – 60, avenue des Landes, 921 50 Suresnes. pp. 195–208. [10] J. Bowlby, Attachment and Loss. Vol. 1. Attachment. Hogarth, London, 1982. [11] W. Hartup, Relationships and their Significance in Cognitive Development, in: R.A. Hinde, A.N. Perret-Clermont, J. Stevenson-Hinde (Eds.), Social Relationships and Cognitive Development. Clarendon Press. Oxford, 1985. [12] G. Preisler, Deaf children in communication. Stockholm University, Department of Psychology (Doctoral dissertation) 1983. [13] D. Stern, The Interpersonal World of the Infant. Basic Books, New York, 1985. [14] N. File, Children’s play, teacher-child interactions, and teachers beliefs in integrated early childhood programs, Early Childhood Res. Q. 9 (2) (1994) 223 – 240. [15] M.J. Guralnick, The peer relations of young handicapped and nonhandicapped children, in: P.S. Strain, M.J. Guralnick, H.M. Walker (Eds.), Children’s Social Behavior, Academic Press, New York, 1986. [16] S. Warren, A.P. Kaiser, Incidental language teaching A critical review, J. Speech Hear. Disord. 51 (4) (1986) 291–299. [17] K. Norde´n, G. Preisler, K. Heiling, E. Hulphers, A.L. Tvingstedt, Learning processes and personality development in deaf children, Int. J. Rehab. Res. 4 (3) (1981) 393 – 395. [18] G. Preisler, Modification of communication by a small deaf girl, Am. Ann. Deaf 126 (4) (1981) 411–416. [19] K. Heiling, The Development of Deaf Children. Signum, Hamburg, 1995.
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[20] G. Preisler, M. Ahlstro¨m, Sign language for hard of hearing children — a hindrance or a benefit for their development? J. Euro. Psychol. Ed. (in press) [21] G. Preisler, A.L. Tvingstedt, M. Ahlstro¨m, Children with cochlear implants — A psycho social follow up study, Paper presented at the Third European Symposium on Paediatric Cochlear Implantation, Hannover, June 5–8, 1996. [22] A.L. Tvingstedt, Social conditions of hearing impaired pupils in regular classes, 1993. Reprints and miniprints, Malmo¨: Malmo¨ School of Education, No 773. Eric reproduction service, No ED 368 150, 1995. [23] A.L. Tvingstedt, Classroom interaction and the social situation of hard-of-hearing pupils in regular classes, 1995. Paper presented at the 18th International Congress on Education of the deaf, Tel-Aviv, Israel, July 16–19, 1995. Eric reproduction service, No ED 392 188, 1995. [24] G. Preisler, Social and emotional development. Blindness and psychosocial development 0 – 10 years, in: V. Lewis, and G. Collis, (Eds.), Blindness and Psychological Development, 0 – 10 years, British Psychological Society (BPS) Books, Leicester (in press). [25] B. Hart, T.R. Risley, Establishing the use of descriptive adjectives in the sponaneous speech of disadvantaged preschool children, J. Appl. Behav. Anal. 1 (1968) 109 – 120. [26] B. Hart, T.R. Risley, Using preschool materials to modify the language of disadvantaged children, J. Appl. Behav. Anal. 7 (1974) 243– 256. [27] B. Hart, T.R. Risley, Incidental teaching of language in the preschool, J. Appl. Behav. Anal. 8 (1975) 411–420. [28] B. Hart, T.R. Risley, In vivo language training: Unanticipated and general effects, J. Appl. Behav. Anal. 12 (1980) 407–432. [29] J.A. Hedenqvist, Spra˚klig interaktion i fo¨rskolan. (Language interaction in the preschool setting). Report no 5. Ho¨gskolan fo¨r la¨rarutbildning, Stockholm, 1987. [30] I. Pramling, Meta-inla¨rning i fo¨rskolan. (Meta-learning in children) Publications from the institute of eductional psychology, Gothenburg University Report 1987 (1986) 9.
.
The development of communication and language in deaf preschool children with cochlear implants Gunilla Preisler a,*, Margareta Ahlstro¨m a, Anna-Lena Tvingstedt b b
a Department of Psychology, Uni6ersity of Stockholm, 106 91 Stockholm, Sweden Department of Education and Psychological Research, Malmo¨ School of Education, Post Box 23 501, 200 45 Malmo¨, Sweden
Received 13 February 1997; received in revised form 23 June 1997; accepted 29 June 1997
Abstract The study is an ongoing longitudinal and qualitative psycho-social study of the communicative development in 19 preschool children with cochlear implants, using sign language. The children are video-recorded in natural interactional settings. Analysis of patterns of communication show that 16 of the children use sign language in communication with adults and peers. With regard to oral communication, 13 children were observed to utter single words or speech-like sounds upon an adult’s request, but seldom used spoken words spontaneously. Six children used single spoken words in dialogues with adults if the content of the dialogue was about the here and now, and if the topic of reference was clear. None of the children in the study were able to take part in age-adequate play activities with peers when speech was used in communication. The results are discussed in reference to early mother–infant interaction, the development of communication and language, and the significance of early close relationships for children’s social and emotional development. © 1997 Elsevier Science Ireland Ltd. Keywords: Psycho-social study; Preschool children; Cochlear implants; Mother – infant interaction
* Corresponding author. 0165-5876/97/$17.00 © 1997 Elsevier Science Ireland Ltd. All rights reserved. PII S 0 1 6 5 - 5 8 7 6 ( 9 7 ) 0 0 0 8 7 - 6
264
G. Preisler et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 263–272
1. Introduction Language learning or language acquistion is about understanding a world of symbols; that something can be represented by something else, that a word or a gesture can represent an object, an event or an idea. Language is a representation of representations [1]. A large part of the discussion about language development in deaf children with cochlear implants (CI) has been about speech perception and speech production. But speech is not synonymous with language. Perceiving or recognizing spoken words and producing or imitating spoken words or sentences does not amount to commanding a language or understanding the symbolic meaning of a particular word or phrase. Language is not an object or a skill which exists outside the child. Rather it is a mode of action into which the child grows because the mode is implicit in the human developmental system [2]. Which are then the developmental growth paths that lead to language? The most common approach to answering this question has, for a long time, been to search for the roots of spoken language in the development of the auditory and vocal modalities and the roots of sign language in the development of the visual-gestual modality. But the most significant things that the infant needs to learn about language from a developmentally point of view are written on the face, body, voice and gesture of those who talk [3]. The primary contribution of the face to communication is that it reveals the emotional state of the speaker as well as the attitude of the speaker towards the listener. Infants are already from birth attracted to the face, particularly the eyes of the caregiver [4]. This is adaptive as the eyes are vital components in the human signalling system implying emotions and social intentions. Shared gaze between infants and mothers contributes to the establishment of object reference [5]. Infants look at their mothers’ eye gaze and head orientation as if they were attempting to find out what she might be thinking about [3]. Infants tend to follow an adult’s line of regard as early as 2–4 months, but more consistently so by 8 – 10 months of age. This enables the infants to appreciate an important concept: the object of the mother’s attention. This might be one of the more important conceptual precursors to lexical acquisition. Mothers also spend a great deal of time looking at the things to which their infants attend. The activity of the face, particularly the movements of the eyes, also conveys some indexical information [3]. Preverbal abilities in children like the use of conventional gestures, such as pointings and showing, symbolic and combinatorial play, imitation and the use of tools are important predictors of language development [6]. The sharing of meaning in joyful interactions and early mutual play with turn-taking qualities are crucial prerequisites for language development [7]. The interdependence of the spoken language and visual cues can be shown in studies of blind children. One problem for blind children is to acquire spoken language. The early language development in blind children is often delayed, some do not speak for several years, in spite of perfect hearing ability [8,9]. This is probably due to the fact that blind children do not use conventional gestures, it is not possible for them to follow the parent’s
G. Preisler et al. / Int. J. Pediatr. Otorhinolaryngol. 41 (1997) 263–272
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direction of gaze, or perceive visually emotional cues from the face of their caregiver, and they do not engage in pretend play until a much later age than a sighted child [8]. The significance of early close relationships for children’s social and emotional development has long been recognized [10]. Relationships are viewed as the context in which socialisation takes place and basic competencies emerge [11] in which communicational skills are acquired [12], and in which the regulation of emotions develops [13]. But studies in child development have also shown how children acquire important developmental skills as a result of peer interactions [14]. Delays in expressive language abilities affects the development of social skills, which in turn can hinder children from becoming involved in more complex forms of peer interaction [15]. The ability to use language as a media for sharing experiences and feelings, for referring to abstract concepts, and for relating to future and past experiences, enables a child to become involved in fantasy and role play. If preschool children are to be able to take part in fantasy play, it is important that they are also given the opportunity to develop close friendships with other children. The importance of providing children with specific difficulties the possibilities to acquire language is stressed [16]. Failure to do so not only has consequences for their language development per se, but also for their emotional, social and cognitive development. The idea that one sign system hinders the development of an other, that is still sometimes held, is by no means valid. Studies from the two last decades in particular, have clearly shown the positive effects of sign language learning in deaf children, not only for communicative, social and emotional development but also for language learning in general [12,17–19]. The current debate in Sweden concerns the choice of language to be used with the moderately to severely hard-of-hearing children. It has not been self-evident to parents and teachers to use sign language with a child who, equipped with a hearing aid, can perceive auditory information and develop spoken language. However, the communicative difficulties these children encounter in interaction with peers, and in larger groups are well recognised by the hard of hearing and by their parents and teachers. As a consequence, many parents now choose to let their hard-of-hearing child attend preschool and primary school education together with deaf children [20].
2. A study of children with cochlear implants In 1981, sign language was declared the official language of the deaf in Sweden. It has now been declared that schools for the deaf must ensure children a development towards bilingualism in Swedish Sign Language and Swedish, mainly in its written form. Today there is an offical consensus that, for a child to be considered a CI-candidate, the family must have an established sign language communication with their child. The child is regarded as a deaf child before implantation as well as after. In Sweden, as in most countries, there is a debate about the ethical aspects of implantation, as well as about how to support the
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families and how to give the children appropriate language stimulation. As the situation is quite different from that of most other countries, with regard to the official attitude to the use of sign language, it was found that most research from other countries was of little value as the majority of CI programs are concerned with giving the child a strictly oral education. Therefore, the National Board of Health and Welfare supported a psycho-social follow-up study of CI children using sign language in Sweden which started in 1995 [21].
2.1. The objecti6e of the study One of the objectives of the psycho-social study is to describe the children’s communicative development and the communicative styles of parents and teachers. The means of communication which are used by the children and adults in different contexts are questions of interest here. The study is one in a series of developmental studies concerning deaf and hard-of-hearing children [12,17–20,22,23] as well as children with functional disabilities like blindness and deafblindness [8,9,24].
2.2. Method The study is longitudinal and qualitative. The children are observed every third month by means of video recordings in natural interactional settings with their parents and siblings, and in their preschool settings with teachers and peers. Direct observations and interviews with parents and teachers about the communicative aspects of the development of the children are also made.
2.3. Description of the children The study consists of all the children born betweeen 19901 and 1994, who received implants before the summer of 1996. Today, 19 children participate in the study. The age and sex of the children are presented in Table 1. A further four children who have recently received their implants, are now about to be visited. The children belong to a total population of 27 children. Of the four children who are not taking part in our study, there is one not using the implant, Table 1 The age and sex of the children in the study Age/Sex
3:0–3:11
4:0–4:11
5:0 – 5:11
6:0 – 6:11
Total:
Girls Boys
2 2
1 1
4 3
3 3
10 9
Total
4
2
7
6
19
1
There is one exception: one child was born during the last days of 1989.
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Table 2 Etiology Etiology
Number of subjects
Meningitis Heriditary deafness Progressive hearing loss
6 9 4
Total
19
in one case the parents consider that too many people already are involved. Contact with the two remaining families has not been established. The families are informed about the research project by the two CI teams and, if they declare that they are willing to participate in the study, they are contacted by us. Nine of the children were born deaf. Six had suffered from meningitis (four of them were reported deaf before the age of 13 months, and the others at ages 2 and 5 respectively). The remaining four children had suffered a progressive hearing loss and had become totally deaf when they were between 2 and 4 years old (See Table 2). The children were between 1:11 and 5:4 years old when they were operated (See Table 3). They started to use the implant approximately a month later, with a mean age of 3:8 years (3:10 for the boys and 3:6 for the girls). The children were first approached when they had used their Nucleus 22 Channel implant between 2 weeks and almost 2 years. Today, (November 1996) they have been using their implants between 4 months and 3 years. The average length of use is 20 months, 18 for the boys and 21 for the girls. All of the childrens’ parents are hearing. Of the 19 children, 15 had already started at special preschools for the deaf and hard-of-hearing before a discussion of implantation was raised. For the remaning four children, there were no other preschool alternatives within a reasonable geographical distance other than a preschool for hearing children, hence this preschool form was chosen. Today, in the fall of 1996, two of the oldest children have started school. One child, born deaf, is attending a school for the deaf, and the other, deaf at the age of 3 years and 6 months, is attending a school for hearing children, accompanied by a signing assistant, 13 of the children attend preschools where sign language is the Table 3 Age of deafness and age at the time of operation Age at operation/ Age of deafness
1:11 – 2:11
3:0 – 3:11
4:0 – 4:11
5:0 – 5:11
Total
Deaf before the age of 2 Deaf after the age of 2
5 —
3 2
4 2
1 2
13 6
Total
5
5
6
3
19
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Table 4 Current preschool and school placement of the children in the study The child is attending:
Number of subjects
(1) Special school for the deaf (2) Mainstreamed with hearing children acc. by a personal assistant (3) Special preschool for the deaf (4) Preschool with group-integrated hard of hearing children (5) Preschool for hearing children acc. by a personal assistant (6) Part time in a preschool for deaf children, part time in a preschool for hearing children
1 1 11 2 2 2
main language. Two of them have also started to attend an ordinary preschool setting with hearing children two days a week. Two children are in preschools with group integrated hard-of-hearing children and another two are in a preschool setting with only hearing children (see Table 4). These children have signing assistants. 3. Results After the first year of video observations and interviews with parents and teachers, the analysis showed that 16 of the 19 children were able to use sign language in interaction with parents, teachers and other adults, as well as with signing peers. They discussed present, past and future events, and the majority of these children (14 of 16) took part in fantasy play. Three children were still learning sign langauge because of late diagnosis of deafness or because they had not had access to a signing environment. As a consequence they still had difficulties in participating in linguistic communication with adults and with other children. Six children (five of which became deaf between the age of two and four, and one was born deaf), were observed to perceive single spoken words in dialogues with their parents or teachers if the content of the dialogues was about the here and now, and if the topic of reference was clear. These children had been using their implants for between 1 and almost 3 years, with a mean duration of 2:8 years. In the above mentioned contexts, the children were occassionally able to respond adequately to questions or comments, either with single spoken words or with lip movements corresponding to spoken words. They were further observed to respond with sign language sentences mixed with one or two spoken words. One of the children used spoken sentences with adults, but depended on sign language in order to understand the meaning of the message. As the adults had difficulities in understanding the child’s spoken language, the child’s articulation was poor, and as the child had just recently started learning sign language, there were considerable problems, both with respect to oral and signed dialogues. Misunderstandings occured frequently and both the child and the adults needed repeated clarifications in order to fully understand each other.
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The other 13 children were observed to utter single words or speech-like sounds upon their parent’s request, but they seldom used spoken words spontaneously. None of the nineteen children were able to take part in ‘age- adequate’ oral dialogues, communicate orally in group settings, or take part in ‘age-adequate’ play activities with hearing or hard-of-hearing peers when speech was used in communication. Soon after implantation all of the children in the study were observed by parents and teachers to react to environmental sounds like church bells, airplanes, telephone and door bells as well as to other children shouting or calling from the room nextdoor. Most of them were observed to react when adults were calling for them from a distance. Parents and teachers reported that all of the children vocalised more since they started to use their implants. The children received special training by a special teacher for the hearing impaired or a speech therapist. Half an hour twice a week was the most common model used. This special training was aimed at making the children attentive to sounds and to discriminate between different environmental sounds as well as speech sounds. In these adult-centered, speech oriented and often very well structured communicative contexts, practically all of the children in the study made efforts to utter spoken words or wordlike sounds. The words were mainly the names of persons or of objects, like ‘Mummy’ and ‘Apple’. However, it was observed in these training sessions that some of the teachers tended to overestimate the children’s ability to perceive sounds, in particular speech sounds, but also environmental sounds played from an audiorecorder. In these cases, the children often showed difficulty in understanding the teacher’s intentions, the meaning of the interaction and even the meaningfulness of the situation. On the other hand, there was a tendency to underestimate the children’s cognitive development. The content of the interaction in these training sessions was often considerably below the children’s intellectual level. For a 4- or 5-year old child who can discuss complex phenomena in the future or the past, it can hardly be stimulating to imitate the sound of a cat or a cow, i.e be treated as a 1–2 year old child. What can also observe from the video recordings—there are today (November, 1996) on average four video recordings of each child—that when demands were put upon the children by teachers or parents to produce speech or speech sounds, the children tended to show aversive or oppositional behaviors. The greater the demands from the adult, the less was the response from the child. They looked elsewhere, looked bewildered, or they looked into the camera, and they even yawned. In the interviews with the parents satisfaction was expressed with regard to the CI-operation and they felt that they had done what was within their power to give their child opportunities to perceive sounds. The majority of the parents were convinced that sign language was of utmost importance for their child’s well-being, enabling them to communicate with peers, parents and teachers. But all of them nourished a hope that someday in the future, their children would be able to communicate with speech, at least to some extent. This would enable their children to take part both in the deaf society and also in the world of the hearing.
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4. Discussion If we compare the first results from our ongoing study of the CI children using sign language with results of international studies of orally raised deaf CI children, we find some common traits: all of the children perceive environmental sounds, and most of them perceive and produce a limited set of spoken words/sentences in well defined contexts. The children who use sign language and attend preschools with deaf children, command a language that enables them to take part in the world around them, to join in and interact with others, and share meanings and ideas with adults and peers. They also receive training from a special teacher for the hearing impaired or speech therapist. These sessions are now under discussion with the aim of improving the possibility of the children to detect and discuss sounds, and to use speech in natural interactional settings depending on their personal ability. The situation of the CI children in preschools/schools where speech is the main language, gives cause for apprehension. Their opportunities to take part in dialogues with peers are limited, they interact mostly with signing adults, and adults often take the role of interpreter for both other adults and children. The importance of play and relations to peers has been emphasised by many researchers. What are the consequences for a child who has an adult functioning as a mediator? It does not promote friendship, as normal peer relations become impossible. The dialogue with other persons is of great importance for the child’s development. In these encounters, the child forms inner models for future encounters and relations. What inner model for encounters and relations will these children form? The view held today is that the child acquires language in natural interactional settings. A number of studies [25 –28] have shown the advantages of using incidental teaching in comparison to traditional language training methods. Other studies have shown that children often react negatively to questions posed by adults which they perceive as inquiries [29]. But questions posed by adults with a clear intention of getting to know the children’s opinions, ideas or views, elicit many more responses from the children [30]. The possibilities for the child to engage in meaningful interaction is to a great extent dependent on the ability of an adult to adapt to a child and to give space for the child to take an active part in the interaction — to follow rather than direct the child. If we regard the children as passive receivers of information, the children might gradually develop a sense of self as passive, or even incompetent and disabled. This will have severe consequences for the child’s social, emotional, communicative and cognitive development. For approximately 20 years now, deaf children in Sweden have been raised as normal children. They have acquired language spontaneously, as hearing children do. They have become bilingual by means of sign language and written Swedish. They have developed a sense of identity as a cultural minority, not as a group of disabled. Their academic achievements are now almost in parity with those of hearing children [19]. In studies of deaf children with cochlear implants, fundamental knowledge based on the latest findings from the field of child development in general, and language development in particular, are seldom or never discussed. The CI children are deaf children. Without the implant they are as deaf as before
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the operation. Even if they will be able to perceive speech and to express themselves orally when using the implant, they will still be socially deaf in the same way as is reported among even moderately hard-of-hearing children [20,22,23]. If we can enable them to become bilingual—in sign language as well as in reading and writing - and to gradually also be able to use speech, then the implant can become something positive, an extra asset for them. But if we solely rely on their ability to take part in social interaction by means of auditory perception through the implant, their future emotional, social and also cognitive development will be at risk.
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