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Scott Webb: We all want to maximize language development in our children, but this is especially challenging for kids with hearing loss. Today, we're going to learn how hearing loss impacts spoken language development in our kids and how auditory verbal therapy, home strategies and the team at Stanford Medicine Children's Health can help kids and families.

And joining me today, our Melissa Tribble, she's the pediatric audiologist manager at Stanford Medicine Children's Health and Rana Barghouty, she's a speech pathologist at Stanford Medicine Children's Health.

This is Health Talks from Stanford Medicine Children's Health I'm Scott Webb. So, first off, I want to thank you both for joining me today. As I was just mentioning, I don't know a lot about this topic, which is why I love hosting these, and I'm sure listeners like listening, to have experts on so that you can help us to understand. So basically, we're talking about maximizing language development in children today with hearing loss and we have you on to do that. So I'll start with you, Melissa. How can hearing loss impact spoken language development and communication?

Melissa Tribble: Hearing losses can actually vary in many ways. They can vary in the degree of hearing loss, like how much hearing loss is present. You know, is it mild? Is it moderate? Is it severe? They can vary in type and they can also vary in whether it impacts one ear or both ears, or if it's temporary or permanent. And these factors can play a role as to the specific way a hearing loss can impact a child and their spoken language development.

So when I consider that and thinking about the impact hearing loss can have on spoken language, there are a few things that come to mind. The first thing that comes to mind, for me, is the fact that hearing loss can reduce a child's access to speech sound. So in other words, it is inaudible. It's going to be inaudible. If specific sounds are inaudible, then over time, the brain will not be able to make sense of that sensory information to make it meaningful. And this is most apparent when the hearing loss is present in both ears.

Another factor that comes to mind is that hearing loss can impact a child's ability to process speech in different listening environments. As you know, our world is a busy place with a lot of auditory distractions. People are talking to us from a distance. There may be background present. And even during this pandemic, people are speaking when wearing masks. So having a hearing loss can make it difficult to understand speech and can make the child with hearing loss need to work much harder with those obstacles present.

So when putting those factors together, it allows us to see that hearing loss' impact on spoken language development is rooted in having access to speech sounds. Without that constant access and consistent access to speech sounds, then a child's ability to communicate using spoken language can be compromised and can result in difficulties with acquiring and successfully using a spoken language.

In our department, we are involved in outpatient newborn hearing screening and diagnostic testing to assist with early detection of hearing loss, so that if a hearing loss is identified, we can begin to not only have the discussion about if a hearing loss is present, but also what intervention may look like for the child, recommend intervention options, and work with the family and community partners to support this family with their language and communication goals for their child.

Scott Webb: Really interesting that you mentioned what we've all been through with COVID and masking and the difficulty. Right on top of hearing loss in one or both ears, you add in the masks. And I know I've had trouble, I've had trouble communicating with people and my hearing, although I'm not as young as I used to be, and it's not as good as it used to be, you know, my hearing's pretty decent and it's been very challenging. So I can only imagine what children with hearing loss have been through, both in their lives, but certainly over the last couple of years. And you talked about intervention there. So let's talk about that. What are the communication options? We're talking about total oral communication, sign language. What are the options that are on the table?

Melissa Tribble: You kind of hit on a lot of them right there. So thank you. So specialists like myself and Rana, we both work with children with hearing loss. We recognize the importance of children having access to language and that building that foundation as early as possible is critical to their overall development. So as you mentioned, these communication options, sometimes they're referred to communication outcomes, are a variety of modalities or kind of modes that one may use to communicate. So you mentioned a few, sign language, which is American sign language. There's listening and spoken language and also total communication.

With American sign language, that is a manual form of communication and it's a true language. It actually follows its own grammar and structure that's different than spoken English. And in different countries, they actually have like British sign language and you may see it in different countries as well, having their own grammar and structure and sign. So it's not always universal as some may think.

And then, you also have listening and spoken language, which really focuses on teaching a child to listen and speak with the assistance of auditory technology, like a hearing aid or a bone conduction hearing device or a cochlear implant.

And then, total communication is a method of communication that will combine a child's use of their auditory device to use their hearing and spoken language as well as utilizing a form of manual communication, whether that be American sign language or signed exact English, which again has a different grammar and structure with that form of communication.

And you know, when we put that all together and you have your child's audiologist and your speech pathologist and early interventionists, all of us together can help to provide guidance and support about these options specifically and what may be most appropriate for a child's hearing loss and their overall desired outcome.

Scott Webb: Yeah, it really does seem like it's sort of a total team effort in helping children and families. And I try to learn, Melissa, something new every day, and I had no idea. I just always assumed that sign language was sign language, right? I didn't realize that it was a different sign language, a unique sign language here, versus as you say, in England, something like that. So thank you for that. I've learned something new, at least one new thing today. That's pretty cool. And Rana, I want to bring you in. I'm familiar with traditional speech therapy to a degree, but what's the difference between auditory verbal therapy and traditional speech therapy?

Rana Barghouty: Auditory verbal therapists like myself are specialized in working with children who are deaf and hard of hearing to develop spoken language. So listening is the foundation for developing spoken language. So auditory verbal therapy or AVT primarily focuses on teaching children how to develop their listening skills and to process auditory information. So unlike children with typical hearing who acquire these skills naturally, children who are deaf and hard of hearing need guidance to first learn to associate sounds with meaning, and then later to comprehend spoken language.

So AVT is also heavily based on parent coaching, which can be a little bit different from traditional speech therapy. The goal is to teach caregivers how to effectively communicate with their child throughout daily routines to develop these skills. So we're essentially teaching caregivers to become language models for the child, using a variety of listening and spoken language strategies. And the goal of AVT is for the child to be on a trajectory toward achieving age-appropriate literacy skills and to mainstream into a regular education setting when they are ready. So we want them to do AVT for as little as possible. The goal is not to have them be doing AVT forever.

Scott Webb: Yeah. And you mentioned the role that parents play, obviously, the very important role that parents play in language development or other caregivers for that matter. So I'm sure that parents listening to this are going to want to know, you know, how can they best communicate with their children at home if, and we know they are, they're really interested in developing listening and spoken language?

Rana Barghouty: So I'm super passionate about this topic and I can talk about it forever. So children's brains are programmed to learn language in the first six years of life, but the first three are the most critical for auditory development. Babies actually make 700 new connections every second in the first three years. So starting as early as possible is super important because we can capitalize on brain neuroplasticity. Children's brains are wired to learn through social interactions. So all parents hold the power to help their child reach their potential. And the basis of learning language really requires attention. That has to come first, access to sound and attention. So I'm going to go through some engaging ways to help children develop language. These will include talking, singing, reading and playing, okay? So I'll go through these in some more detail to give parents some practical tools to have.

So the ultimate goal of language development is really to engage in conversation, right? And this requires turn taking. I say something, then you say something. And so you can focus on developing this skill early on, even with babies. For example, any movement or sound your baby makes even a burp can be considered a conversational turn. With toddlers, you should always carry on the conversation, even if you have no idea what they are saying. Using some wait time, maybe counting to 10 in your head to give them a chance to respond is really important because early listeners need time to process what is said and to give a response back. Sometimes we're so quick to rush in and kind of want to add in language. But if you just waited a few extra seconds, sometimes children will come out with a response and surprise you.

So next I want to talk about reading a little bit. It's never too early to implement a book routine with your child. Reading is the foundation to academic success and reading aloud with your child is the biggest contributing factor in developing vocabulary, encouraging parent-child conversations and creating those neural pathways needed for developing reading. So even if your baby has a limited attention span and they just want to put the book in their mouth, keep trying to work on readings because their attention will continue to increase over time. Even if it's just increasing by a few seconds every day. It makes a difference over time and we see babies begin to show more interest in reading around about four months. But again, never too early to begin. You can even kind of read a textbook with your newborn and just have them be listening to language. So when your child is becoming more engaged with reading, you can go beyond the words of the book to add more language. Like you can talk about the pictures or whatever your child's attention is on, and you can also relate what you're reading to your child's own real life experiences instead of just sticking to the words in the book.

Asking questions like, "What's this? What's that?," we see a lot of parents do this and it's not very helpful because we're only asking the child to retrieve words that they already know when we're asking them these questions. So instead, asking more open-ended questions, like how or why questions or using language to be more descriptive and commentative, and being a good model of language to them is going to be more helpful.

So next, I want to talk a little bit about singing. Music is one of the best methods to develop listening skills because it's repetitive. It has rhythm, rhyme and it really improves speech perception, which is so important when we're looking at hearing loss. Interestingly, singing also works both sides of the brain. So a lot more connections are happening when children are listening to you sing than listening to you talk. And singing is just super fun. So I encourage parents to sing as often as possible, sing nurse rhymes, make up your own songs. Research actually shows that children who know more nursery rhymes by kindergarten will later have higher language skills and reading scores. So I can't emphasize singing enough.

For babies, we can use finger plays with songs to help maintain their attention. So while you're singing, you can kind of do some movement with your hands, like with Twinkle, Twinkle or Itsy Bitsy Spider. And if they're older, you can help them finish a phrase in a song like, "Twinkle, twinkle little..." and then really use that wait time that we talked about earlier to help them produce the last word.

And then lastly, children learn best through play. And play and language go hand in hand. So at first, children use play to learn language. So AVT really is just us playing with the child, but we're really doing therapy. And later, children will use language to advance their play skills. So I encourage parents to turn the TV off, put your phones away, get on the floor with your child at their ear in their eye level and play with them often to really cultivate these skills.

Scott Webb: So much of what you said there brought a smile to my face. You know, I was just thinking back to all the book chewing. You know, we were trying to read books, but we did a lot of chewing on the books. And, you know, this has been really educational. I want to thank you both today. And Rana, I know that hearing loss can impact pragmatic language development in children obviously. I want to have you address that, but also how you and the team at Stanford Medicine Children's Health can help children and families as well.

Rana Barghouty: Pragmatic language skills are the most abstract and complex of all language skills and pragmatic skills are really just social skills. So some examples of pragmatic skills are following rules for conversation like initiating conversation, staying on topic, taking appropriate turns, not interrupting, things like that. And children who have typical hearing acquire pragmatic skills naturally through overhearing, which is called incidental learning. And these skills quickly increase between ages three and four, and they continue to develop over time.

So children who are deaf and hard of hearing acquire these skills much more slowly because they have more challenges hearing in the presence of noise and hearing at longer distances. So because they have less opportunities for incidental learning, many skills involving pragmatic social communication need to be directly taught. So these are things that we work on when we're doing AVT, and they're best worked on in, you know, social groups, in the classroom, and in those kinds of settings. Also, children with hearing loss tend to be very concrete thinkers. So they sometimes have challenges with being able to understand sarcasm and jokes, figurative language, and to identify other people's emotions in their tone of voice. So sometimes, we have to talk about these things a little bit more explicitly with children to explain.

We also see children with hearing loss have more challenges with executive functions and theory of mind. So executive functions include your working memory, so kind of hearing something through listening and holding it in your memory to do something with that information. Executive functions also include self-control, regulating emotions, flexible thinking, planning and organizing. It's a whole list of functions and theory of mind or perspective taking, as some people call it, is being aware of the mental states of other people, such as awareness of other people's knowledge, their intentions, their feelings, and so on, so kind of the unspoken rules and guidelines of language and conversation beyond just actual language. So we address a lot of these things in therapy and in the classroom, in social groups. We talke to parents about it early on, so that they're addressing them just in their daily routines.

So overall, hearing loss goes way beyond just gaining, you know, improved access to sound and learning language, but early intervention and collaboration of caregivers and appropriate professionals working as a team is really what allows children to reach their potential, despite their hearing loss. And, you know, when all of the pieces of the puzzle are in place and everybody is doing the right thing, it's amazing the outcome. A lot of the age children can develop very typically when all the things are happening as they should be.

Scott Webb: So Melissa, as we wrap up here, I just want to give you an opportunity to talk about the program there are at Stanford Medicine Children's Health, like specifically, what can folks expect, what makes the program unique and why you'd want them to reach out, especially if they think or they know for a fact that they have a child with hearing loss?

Melissa Tribble: Our team is unique, I think just because we all really love what we do, we love the families that we get to work with and we love collaborating. And so just even based on today's discussion with Rana here, you know, we are a close team that tends to be on the same page and likes to work together to help families, get the services that they need. So what's specific for our team and what we take advantage of is having a specialist like Rana, who is certified in auditory verbal therapy to collaborate in our appointments directly. And so some families are able to benefit from having visits with the audiologist and the auditory verbal therapist present so that we can work together to make sure that the child is progressing as needed. We can work together to make real time decisions about programming of devices. We can collaborate to come up with the good plans and I think it just helps to give that balanced approach to making sure that all of the components are meeting their needs to help the child succeed. And I think that that's something that's definitely unique for our team here at Stanford Medicine Children's Health.

Scott Webb: What's the saying? It takes a village, right? And it definitely takes a team between you and your team and parents and caregivers. And as you say, everybody doing the right thing, the results can really be amazing. And I found this conversation to be amazing, really educational. Not just learning more about sign language, but in general, how you and the team there at Stanford Medicine Children's Health are working to help children and families and the amazing results. So thank you both and you both stay well.

Rana Barghouty: Thank you.

Melissa Tribble: Thank you. You too.

Scott Webb: And for more information, go to stanfordchildren.org/en/service/hearing-center. And we hope you found this podcast to be helpful and informative. If you did, please share it on your social channels and be sure to check out the full podcast library for additional topics of interest. This is Health Talks from Stanford Medicine Children's Health. I'm Scott Webb. Stay well, and we'll talk again next time.