Demographics

Approximately 95% of children identified as DHH are born to hearing parents, into homes where spoken languages are in use at the time of birth (Gallaudet Research Institute [GRI], 2013; Mitchell & Karchmer, 2004, 2005). Less than 5% have two parents who are DHH with native sign language proficiency. Approximately 35% of children in the United States come from homes where languages other than English or American Sign Language (ASL) are used (GRI, 2013; Mitchell & Karchmer, 2004; White, 2018). According to a survey of DHH children and youth, more than half of DHH students received education in spoken language–only environments, 15.2% were taught using sign language only, and 13.3% were taught with both signed and spoken languages (GRI, 2013). Forty percent of DHH children have multiple disabilities that may require more specialized supports and services, such as AAC systems (GRI, 2013; Mitchell & Karchmer, 2006; Roush & Wilson, 2013).

Early Hearing Detection and Intervention (EHDI) newborn hearing screening programs referred 86% of infants identified as DHH for early intervention services. Of those referred, 66.6% enrolled in the recommended early intervention services (Centers for Disease Control and Prevention, 2021). In 2019, approximately 7,985 preschool children (3–5 years old) received special education services with an individualized education program (IEP) for hearing-related services. For school-age children (6–21 years old), 64,102 students received special education services under the Individuals with Disabilities Education Act of 2004 (IDEA) disability category of hearing impairment (see ASHA’s resource on hearing-related topics: terminology guidance). Among those school-age children, 88.6% spent some portion of their school day in a regular education program, whereas 11.5% received education in another environment such as a separate school or residential facility (Office of Special Education Programs, 2021). More than 100 schools and programs designed specifically for DHH students are available across the United States (Laurent Clerc National Deaf Education Center, n.d.-c).

Federal/State Laws and Regulations

Various federal laws, regulations, and programs impact the education and provision of audiology and speech-language pathology services for children who are identified as DHH.

• Section 504 of the Rehabilitation Act of 1973
• Education of the Deaf Act of 1986
• Americans with Disabilities Act of 1990 (ADA)
• Individuals with Disabilities Education Act of 2004 (IDEA)
• Every Student Succeeds Act of 2015 (ESSA)
• Early Hearing Detection and Intervention Act of 2021 (EHDI)

Some states also have their own legislation or policies that affect services and educational plans for DHH children (e.g., Bill of Rights for Deaf and Hard of Hearing Children).

See Federal/State Laws and Regulations Related to Service Provision for Children Who Are Deaf and Hard of Hearing (DHH) for more information on federal and state legislation.

Roles and Responsibilities

An interprofessional team approach to family-centered service delivery fosters linguistic and communicative competence in children who are identified as DHH. The Joint Committee on Infant Hearing (JCIH, 2019) describes knowledge, skills, and roles important for audiologists and SLPs as well as other team members. In addition to audiologists, SLPs, and families/care partners, other team members may include, but are not limited to,

• Deaf mentors and coaches;
• developmental specialists, pediatricians, and otolaryngologists;
• early interventionists;
• listening and spoken language specialists;
• occupational and physical therapists;
• sign language specialists; and
• teachers of the Deaf / hard of hearing

The roles and responsibilities of these individuals may be overlapping, complementary, and/or supplementary when collaborating to achieve optimal outcomes depending on the needs of the child. Each individual brings unique education and expertise to the process (ASHA, 2004a, 2004b, 2004c).

For further information, see the JCIH 2019 Position Statement (JCIH, 2019), JCIH 2007 Position Statement (JCIH, 2007), and Supplement to the JCIH 2007 Position Statement (ASHA, 2013).

See also Supporting Students Who Are Deaf and Hard of Hearing: Shared and Suggested Roles of Educational Audiologists, Teachers of the Deaf and Hard of Hearing, and Speech-Language Pathologists [PDF] from the Educational Audiology Association (2018), ASHA’s other hearing-related Practice Portal pages, and ASHA’s resources on Collaboration and Teaming and Interprofessional Education/Interprofessional Practice (IPE/IPP).

Speech-Language Pathologists

SLPs play a central role in the screening, assessment, and provision of speech, language, literacy, and cognitive-communication services for children who are identified as DHH. Professional roles and activities include clinical and educational services (diagnosis, assessment, planning, and treatment, including family/care partner counseling); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles and responsibilities for SLPs include, but are not limited to, the following:

• Maintain knowledge of anatomy, physiology, and pathophysiology of the auditory system as well as audiogram interpretation.
• Understand that hearing loss may impact access to spoken language.
• Recognize the differences in characteristics and outcomes among languages that are spoken, signed, written, and/or generated through assistive technology and the role models/communication skills needed to stimulate language development.
• Educate families/care partners about the variety of language modalities (signed, spoken, and other/AAC), communication tools, strategies, and programming available so they can make informed decisions about what is best to help achieve their child and family’s desired outcomes. SLPs acknowledge that language modalities and techniques may change over time as the child’s best learning and communication styles are identified.
• Provide comprehensive, culturally and linguistically appropriate evaluation of speech, language, cognitive, social, and/or other communication skills.
• Establish communication goals regarding developmental milestones and academic achievement as well as social interaction.
• Provide services using appropriate languages and communication systems, depending on the child’s needs, and collaborating with interpreters when necessary.
• Establish AAC techniques and strategies including developing, selecting, and recommending systems and devices, when indicated.
• Use formal and informal evidence-based measures to gather information on auditory development, speech perception, and functional listening behaviors in children developing spoken language.
• Create and implement an individualized aural (re)habilitation plan of care.
• Monitor language and communication competence (signed and/or spoken) and cognitive skills in a variety of settings as well as progress toward goals using data and functional outcome measures.
• Maintain general knowledge of hearing technologies and their function/maintenance.
• Perform routine visual inspection and listening checks of hearing technologies for purposes of troubleshooting.
• Remain current on assistive technology and accommodations designed to facilitate access to speech, language, social interactions, and/or classroom instruction.
• Provide consultation regarding accessibility, participation, and appropriate service provision for children who are identified as DHH in public and private buildings (paying particular attention to the general education classroom setting).
• Refer to other professionals and organizations to facilitate access to comprehensive services, including social–emotional supports, parent-to-parent networks, and peer mentoring.
• Counsel children and their families regarding communication outcomes, self-advocacy strategies, and rights to services.
• Advocate for children who are identified as DHH and their families at the local, state, and national levels.
• Promote resources for research, evaluation, and program development.
• Conduct research to study DHH children’s speech, language, cognitive, academic, social, and other communication development, needs, and outcomes to expand evidence-based practice in the profession.

As indicated in the ASHA Code of Ethics (ASHA, 2023), SLPs engage in only those aspects of the profession that are within the scope of their professional practice and competence. SLPs who serve this population should be specifically educated and trained to do so using the child and family’s desired language(s) and communication outcomes, collaborating with sign and spoken language interpreters when necessary.

Audiologists

Pediatric and educational audiologists have critical roles in the screening, assessment, diagnosis, treatment, and provision of aural (re)habilitation and support services for children who are identified as DHH. Professional roles and activities in audiology include clinical and educational services (assessment, diagnosis, treatment, and accommodations); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).

Appropriate roles and responsibilities for audiologists include, but are not limited to, the following:

• Oversee early hearing detection and intervention (EHDI) programs and implement benchmarks set by the JCIH.
• Report results of newborn hearing screenings and/or hearing evaluations to families, state EHDI systems, and follow-up programs.
• Conduct comprehensive, culturally and linguistically appropriate audiologic assessments to establish an accurate diagnosis of hearing status.
• Provide information about the child’s hearing status and eligibility for EHDI services to others involved in the child’s care, such as the referral source, primary care provider, and designated early intervention center with the family’s consent.
• Educate families/care partners about the variety of languages (e.g., signed, spoken, AAC), communication systems, strategies, and programming available so they can make informed decisions about what is best for their child and family.
• Provide family support and counseling regarding the nature of auditory access and implications for language, cognitive, social, and academic development strategies/accommodations; device/technology use; and acoustic modifications.
• Coordinate timely audiologic services—including evaluation, fitting, programming, and maintenance of hearing aids, cochlear implants, other sensory devices, and assistive technology.
• Verify and validate that devices are providing the intended benefit.
• Monitor the child’s hearing status and manage hearing technologies for proper use, care, and function and provide training, troubleshooting, and guidance when adjustment is necessary.
• Coordinate with team members to develop and implement appropriate, comprehensive auditory (re)habilitation plans that address listening/communication strategies, classroom acoustics, social–emotional skills, and self-advocacy.
• Gather formal and informal information on speech recognition, auditory detection, functional listening skills, social participation, and quality of life.
• Develop and use ongoing progress data and functional outcome measures.
• Refer families/care partners to other professionals, parent-to-parent support groups, and consumer-based organizations.
• Educate consumers and other professionals about the needs of children who are identified as DHH and the role of audiologists.
• Actively participate in interdisciplinary team meetings about education, services, and supports.
• Advocate for the rights to and funding of services for children who are identified as DHH.
• Remain informed of and engage in research related to language, speech, and/or auditory development in children who are identified as DHH.

As indicated in the ASHA Code of Ethics (ASHA, 2023), audiologists shall engage in only those aspects of the profession that are within the scope of their professional practice and competence, considering their levels of education, discipline-specific training, and experience. The roles of the audiologist will also be guided by state licensure regulations.

Guiding Principles for Development of Linguistic and Communicative Competence

Guiding principles for promoting language, literacy, and communicative competence in DHH children include the following.

• Children and families have timely access to high-quality early intervention services. Early identification and intervention are critical for DHH children to develop auditory, language, and speech skills. DHH children can achieve communicative, academic, and social–emotional outcomes that match their cognitive abilities and expected developmental milestones when early intervention and exposure to high-quality, fully accessible language input begin as quickly as possible—ideally between 3 and 6 months of age for those identified at birth (ASHA, 2013; JCIH, 2007, 2019; May-Mederake, 2012; Moeller et al., 2013; National Association of State Directors of Special Education [NASDSE], 2018; Sass-Lehrer, 2016; Tomblin et al., 2014, 2015; Vohr et al., 2012, 2014; White & Muñoz, 2014; Yoshinaga-Itano et al., 2010, 2018). Please see Position Statements from the Joint Committee on Infant Hearing for further information.

• Services are family centered and capacity building. Family-centered practices are responsive to each family’s unique circumstances, reflect a family’s preferred outcomes and goals for their child, and emphasize family involvement in planning and decision making (Division for Early Childhood [DEC], 2014; IDEA, 2004). Opportunities for families/care partners to directly participate in services, strengthen existing knowledge and skills, and develop communication abilities enhance child and family outcomes (Costa et al., 2019; Cruz et al., 2013; DEC, 2014; Harrison et al., 2016; Sass-Lehrer, 2016). High levels of family engagement promote successful language development outcomes in children who are identified as DHH (ASHA, 2008; Houston & Bradham, 2011; Meinzen-Derr et al., 2011; Moeller et al., 2013, 2016).

  See also ASHA’s resources on family-centered practice and person- and family-centered care.

• Services are culturally and linguistically responsive. Culturally and linguistically responsive services support the needs, values, beliefs, and customs of children who are identified as DHH and their families/care partners (Bunta et al., 2016; Crowe et al., 2013; Douglas, 2011a, 2011b; Peredo, 2016). Many children come from multilingual families where a range of spoken and/or signed languages are used (Crowe & Cupples, 2020). Some children are fully immersed in Deaf culture, whereas others do not associate with the culture at all—depending on their home environments, preferences, and communication partners (NASDSE, 2018).

  Cultural dimensions influence family/care partner decisions about services and supports (see ASHA’s resource on examples of cultural dimensions). Perceptions of disability and/or a culture’s beliefs and traditions may impact decisions to seek interventions or may affect how a family/care partner approaches language and communication. People who identify as part of the Deaf community may view being deaf or hard of hearing as a cultural and linguistic difference rather than a disability. Other cultures may place specific emphasis on spoken languages.

  SLPs and audiologists provide information to families/care partners in the language and manner that match their learning style(s) and communication preferences. Assessment by a provider fluent in the language of the home and the child increases the validity and reliability of assessment results (Caesar & Kohler, 2007). Providers work with families, qualified interpreters/translators, deaf professionals, and teachers of English language learners (ELLs) to support their heritage language(s) and acquisition of the academic language for children who are acquiring more than one language. They also collaborate to distinguish language differences that are associated with a multilingual environment from speech/language disorders and identify the language(s)—spoken and/or signed—in which the child will be most proficient for daily communication (ASHA, 2004a, 2004b, 2004c, 2013; Douglas, 2011a, 2015; JCIH, 2019; NASDSE, 2018).

  See ASHA’s resource on IDEA Part C: Cultural and Linguistic Diversity and the Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness.

• Qualified providers who have specialized knowledge and skills working with DHH children deliver comprehensive, coordinated, and team-based services. Families and interdisciplinary providers collaborate to support ongoing successful outcomes for speech, language, literacy, cognitive, and social–emotional development and learning. Providers are trained to educate and counsel DHH children and their families/care partners. Providers are also skilled in assessments, tools, technologies, and strategies that support the development of linguistic/communicative competence. Telepractice may be an option to connect DHH children and their families/care partners with professionals who have the specialized knowledge and skills they need (ASHA, 2004a, 2004c, 2008, 2013; Behl et al., 2017; Galvan et al., 2014; Harrison et al., 2016; JCIH, 2019; Laurent Clerc National Deaf Education Center, n.d.-a; Moeller et al., 2013; Sass-Lehrer, 2016; Stredler-Brown, 2017). Please see ASHA’s Practice Portal page on Telepractice for further information.

• Services are individualized, based on the highest quality internal and external evidence available. Children who are born DHH may have different needs than children with postlingual hearing loss, children with unilateral hearing loss and bilateral hearing loss have different needs, and children with cochlear implants also have unique needs (Nussbaum & Scott, 2011). Planning for language and communication development is individualized, systematic, and guided by evidence-based practices. It includes ongoing assessment in the child’s most proficient mode of communication and monitoring using methods validated for DHH children (ASHA, 2013; JCIH, 2019; Laurent Clerc National Deaf Education Center, n.d.-a; Wolfe, 2019). Providers integrate (a) research, (b) professional judgment and expertise, (c) child characteristics, and (d) family strengths, preferences, and values to deliver efficacious services. See ASHA’s Evidence-Based Practice (EBP) webpage for guidance on evidence-based decision making.

• Services reflect informed and shared decision making by families/care partners based on the child’s language and communication needs. Families/care partners make decisions over time that impact their child’s linguistic and communicative competence. Professionals support them by providing early access to accurate and up-to-date evidence-based information about all languages, communication tools, technologies, programs, and resources. They also provide comprehensive guidance about developmental milestones, specific interventions, and expected outcomes. Families/care partners weigh this information, assessment results, their child’s strengths and needs, and their own goals for communicating with their child, as well as their values, cultural beliefs, and circumstances, to make decisions (ASHA, 2013; JCIH, 2019; Knoors, 2016; Moeller et al., 2013, 2016; Porter et al., 2018; Scarinci et al., 2018).

  For additional information on languages as well as communication tools and systems, see the resource page on Languages and Communication Systems for Deaf and Hard of Hearing Children.

• Early and full access to a complete language is essential for optimal language learning. DHH children may have challenges acquiring language and meeting expected milestones because of limited access to language through auditory means or limited access to proficient sign language users (Lederberg et al., 2013). When children do not have opportunities to access language fully and effectively in their daily routines during critical development periods, it can affect linguistic and communicative competence as well as cognitive, speech, social–emotional, and literacy skills (M. L. Hall et al., 2019; Humphries et al., 2016; Moeller et al., 2013). The widely accepted term for these negative effects is “language deprivation” (Glickman et al., 2020; W. C. Hall et al., 2017). A strong language foundation is key to school readiness, academic achievement, and long-term outcomes (Cheng et al., 2019; Ching et al., 2018; Kushalnagar et al., 2010; Laurent Clerc National Deaf Education Center, n.d.-b; Moeller et al., 2016; Tomblin et al., 2015).

• For children and families with the goal of listening and spoken language, two actions are essential for children to develop listening and spoken language skills: (1) early fitting of amplification, implantable devices, or other assistive technologies and (2) ongoing monitoring of their effectiveness. Children and families benefit from the earliest possible access to well-fitted hearing technology and alerting devices, per JCIH guidelines. The development of listening and spoken language requires optimal amplification and ongoing audiologic follow-up (ASHA, 2008; Geers & Nicholas, 2013; JCIH, 2019; Laurent Clerc National Deaf Education Center, n.d.-a; May-Mederake, 2012; Moeller et al., 2016; NASDSE, 2018; Nicholas & Geers, 2007; Sininger et al., 2010; Tomblin et al., 2014, 2015). However, it is vital to continue to monitor DHH children’s progress with listening devices, as early amplification and intervention does not guarantee full access to and development of spoken language. Please see ASHA’s Practice Portal pages on Hearing Aids for Children and Cochlear Implants for further information.

• Services offer access to support and mentorship from other trained families/care partners and individuals who are identified as DHH. Families benefit from interactions with other families/care partners of DHH children who are trained to provide culturally and linguistically responsive support and guidance. Direct access to hearing families with DHH children and DHH peers and adults with varying hearing levels who communicate in different ways provides language and communication models for children as they grow. These contacts are valuable for self-awareness and social–emotional well-being as well as speech, language, and social communication development (ASHA, 2013; Beal-Alvarez, 2014; Hamilton & Clark, 2020; Henderson et al., 2016; JCIH, 2019; Moeller et al., 2013; NASDSE, 2018; Sass-Lehrer, 2016; White, 2018).

• Services are guided by regular monitoring of the child’s and family/care partner’s desired outcomes. All DHH children, regardless of hearing level or type/degree of loss, require consistent and frequent progress monitoring so that developmental progress and status changes are identified and managed quickly. This includes assessment of language (spoken, signed, and/or written) and communication modality (auditory, visual, and/or augmentative), speech (if applicable), cognitive skills, literacy, and social–emotional functioning as well as accommodations where indicated. The goal of structured monitoring at regular intervals is to record functional and participation-based outcomes, identify facilitators or barriers, and make necessary adjustments as indicated to ensure that development is on track, services are timely and delivered with fidelity, and no child or family falls through the cracks (ASHA, 2013; Ching et al., 2018; Daub & Cardy, 2021; JCIH, 2019; Lederberg et al., 2013; Moeller et al., 2013; Moeller & Tomblin, 2015; NASDSE, 2018; Szarkowski et al., 2020).

Comprehensive Assessment

Assessment of language and communication of DHH children includes (a) formal and informal methods and (b) interdisciplinary collaboration across settings. Consider the purpose of the assessment, the child’s age, the time of onset and/or identification, and the language(s) and/or communication systems being assessed when selecting assessment tools and approaches (Mann et al., 2014; Pizzo & Chilvers, 2019).

Consistent with the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) framework (WHO, 2001), audiologists and SLPs conduct comprehensive assessments to identify and describe the following (M. L. Hall, 2020; Herman, 2015; JCIH, 2019; NASDSE, 2018; Pizzo & Chilvers, 2019):

• Body functions and structures, including underlying strengths and needs in all applicable languages to address questions about a child’s hearing, cognitive–linguistic development, and/or learning.
  • What is their current hearing status?
  • Has their hearing status changed since previous audiologic assessment?
  • What is the impact of their current hearing status on language development?
  • Are they progressing from their developmental baseline (in linguistic, cognitive, and social domains)?
• Co-occurring conditions, such as developmental or learning disabilities, illnesses, and genetic syndromes that may impact a DHH child’s language; communication; and cognitive, behavioral, or social–emotional function.
• Activity and participation, including functional communication and interpersonal interactions at home, in social settings, at school, or in the community.
  • Can they effectively communicate with family and friends?
  • Do they have access to the language of instruction in a classroom setting?
  • Do they have appropriate accommodations and opportunities to participate in classroom activities (e.g., whole class, small group with hearing peers)?
  • Is there an educational disability that makes the child eligible for services?
  • Are they mastering the developmental skills appropriate for their ages and cognitive functioning to promote literacy and learning?
  • Based on current progress, does the child require intervention to support curriculum and transition to postsecondary activities?
  • Do changes need to be made to existing plans for language and communication, service delivery, and/or educational placement?
• Contextual (environmental and personal) factors that serve as barriers to or facilitators of successful communication and life participation across settings (home, educational, other), such as applicable auditory, visual, and educational strategies; technologies; modifications; exposure to a fully accessible language; and/or accommodations.
  • What is their language input/access across settings (home, educational, other)?
  • What mode of communication do they use to express themselves across settings (home, educational, other)?
  • What is the current language(s) of instruction?
• The impact of communication strengths/needs and self-advocacy skills on the quality of life of the child and family/care partners

See ASHA’s resource on Person-Centered Focus on Function: Hearing Loss in the School-Aged Child [PDF] for examples of assessment data consistent with the ICF framework.

Assessment Components—What to Assess

Many states’ early intervention and educational systems have their own assessment protocols that outline assessment components, tools, and procedures as well as expected spoken English and ASL milestones. Some states have centers or offices for the Deaf and Hard of Hearing and schools for the Deaf that offer collaborative consultation and evaluation. Information from multiple sources in different contexts provides the most comprehensive assessment of a child’s strengths and needs to help identify necessary services/supports.

Factors Related to the Child and Family

• Developmental, medical, educational, and family history
  • age of onset/confirmation and etiology
  • age of full-time access to hearing device(s), history of device use, and make and model of all hearing devices if applicable
  • developmental milestones
  • health concerns, genetic syndromes, and disabilities
  • previous assessments and services (e.g., screening and audiologic testing results, timeliness of follow-up, early intervention or school placements and services, accommodations)
  • cultural, linguistic, and educational factors
  • family/care partner/child concerns, priorities, and available resources/supports
  • environmental considerations
• Language history
  • cumulative experience with auditory or visual input (i.e., exposure) and access to that linguistic input in early childhood (Ambrose et al., 2014, 2015; De Anda et al., 2016; M. L. Hall, 2020; M. L. Hall & De Anda, 2021; M. L. Hall et al., 2019; Moeller & Tomblin, 2015; VanDam et al., 2012; Vohr et al., 2014)
  • language(s), communication systems, and technologies used and/or tried
  • desired outcomes and language(s) and systems; primary home/school language
  • communicative and linguistic milestones, abilities, and needs
  • family/care partners–child interaction

Factors Related to the Child’s Abilities

• Auditory status/function, as applicable (e.g., for alerting, for listening and spoken language)
• hearing levels
• use and effectiveness of personal hearing devices and hearing assistive technology
• perceptual check using established protocols (e.g., Madell & Hewett, 2022)
• auditory skill development: information regarding discrete auditory skills across the continuum of awareness/detection, discrimination, identification, and comprehension (e.g., Cochlear Integrated Scales of Development)
• speech discrimination in quiet and noise, including impact of distance and visual access
• functional listening and speech perception skills (e.g., environmental sounds, music, words, conversation, classroom lectures, telephone, suprasegmentals; Estabrooks et al., 2020; Perigoe & Paterson, 2013; Rosa-Lugo & Allen, 2011)
• Expressive and receptive language (spoken and/or signed, as applicable to the child). It is critical to assess if a child is achieving appropriate mastery of expressive/receptive milestones for at least one language, given their chronological, developmental, and/or hearing age (Quinto-Pozos et al., 2011; Simms et al., 2013). Areas to examine include the following:

• prelinguistic and early linguistic skills (vocalizations, gestures, facial expressions, joint attention, verbal and nonverbal imitation, vocal/manual babbling)
• phonology, including phonological awareness (sounds or ASL handshapes, movements, locations, palm orientations, and nonmanual markers; Corina et al., 2014; Fenlon et al., 2018)
• semantics
• morphology and syntax
  • affixes and word order in spoken and signed languages
  • use of space, repetition, verb aspect, and other morphological markers in signed languages (Hill et al., 2018)
• pragmatics/social communication (Goberis et al., 2012; R. Paul et al., 2020; Toe et al., 2020; Yoshinaga-Itano et al., 2020)
• discourse-level skills (e.g., conversation, narratives)
• visual systems used with spoken language (e.g., cueing, sign-supported speech)
• role of signs for language and communication (e.g., foundational, transitional, strategic, dominant, bimodal–bilingual; Nussbaum, Waddy-Smith, & Doyle, 2012)
• proficiency and demands in everyday contextual conversational language and in more formal context-reduced language used in academic settings
• Written language (literacy)
• pre-literacy/emergent skills (e.g., phonemic/phonological/print awareness, narrative play; J. A. Scott et al., 2019)
• reading/writing, including letter and word recognition, word knowledge/decoding, discourse, spelling, grammatical structure, understanding and conveying meaning, organization, fluency, and automaticity (Flexer, 2017; Werfel, 2015)
• social and academic proficiency (Gárate, 2014; Mayer & Trezek, 2018)
• use of comprehension strategies (Banner & Wang, 2011; Duke et al., 2011; Mokhtari & Reichard, 2002; Wang et al., 2018)
• impact of auditory input and language access on phonological abilities and writing conventions versus content (Easterbrooks et al., 2015; Lederberg et al., 2013, 2014; Pizzo & Chilvers, 2019)
• the need for an alternative instructional approach(es) to support development of early language and literacy skills (e.g., sign language, sign language phonology, fingerspelling, visual phonics)
• Speech (for children using spoken languages)
• oral-motor structure and function
• articulation of vowels and diphthongs as well as consonants and phonological processes (Perigoe & Paterson, 2015)
• competence for speech production; overall intelligibility in conversation (Ertmer, 2011; Freeman et al., 2017)
• impact of access to acoustic information (i.e., speech perception) on speech quality and error patterns (Cole & Flexer, 2019; Lamb, 2013; Perigoe & Paterson, 2013, 2015)
• voice/prosody, particularly breath control and suprasegmentals (Coelho et al., 2015)
• resonance (e.g., nasality)
• fluency
• Sign articulation (for children using signed languages)
• fine and gross motor structure and function as related to sign production
• accuracy, fluency, and intelligibility of sign and fingerspelling production
• Cognition (particularly for language-related cognitive abilities)
• executive function (M. L. Hall et al., 2018; Kronenberger et al., 2020; Nicastri et al., 2020)
• theory of mind (Schick et al., 2007)
• attention, auditory versus visual distractibility, memory, reasoning, problem solving, and metacognition (e.g., awareness of communication and comprehension breakdowns)
• Social, emotional, and behavioral
• play skills and friendships
• ability to interpret and engage in social situations
• independence with communication
• self-determination, self-regulation, and self-advocacy (Laurent Clerc National Deaf Education Center & Boston Children’s Hospital, 2015; Luckner & Becker, 2013; Luckner & Sebald, 2013; Millen et al., 2019)
• AAC needs, if applicable (Meinzen-Derr, 2018; Meinzen-Derr et al., 2019, 2021; also see ASHA’s Practice Portal page on Augmentative and Alternative Communication)
• Use and effectiveness of communication/hearing technologies, modifications (e.g., providing additional test instructions), and accommodations (e.g., digital modulation [DM]/frequency modulation [FM] systems, captioning, extra time, interpreters/transliterators)

Factors Related to the Child’s Environment

Assess the child’s environments (e.g., home, school, community) for access to communication and learning and to identify potential barriers and necessary accommodations, as applicable. NASDSE (2018) and Spangler and Flexer (2015) indicate consideration of the following:

• Visual access
  • lighting
  • seating/sight lines
  • visual distractions
  • available visual supports (e.g., print, pictures)
  • alerting and other visual technologies
• Auditory access
  • noise/speech-to-noise ratio, reverberation (echo), and distance from speakers (e.g., home/classroom/school acoustics)
  • alerting technologies
  • assistive listening devices
  • troubleshooting and self-advocacy strategies to address communication
• Educational access
  • available technologies, accommodations, and modifications (e.g., captioning, note-takers, interpreters/transliterators, testing)
  • direct communication with teacher and peers
  • connection between hearing technologies and assistive technologies
  • teacher presentation style, including pace and comprehension/clarification strategies
  • classroom management and participation
  • peer groups and inclusion
  • participation in large groups (e.g., assemblies)
  • safety protocols for emergency situations
  • family–school communication; engagement in IEP/504 process (Laurent Clerc National Deaf Education Center & Boston Children’s Hospital, 2015)

Consider information across these component domains to develop the most appropriate language and communication goals based on the child’s and family/care partner’s goals as well as on the child’s strengths, functional needs, sensory abilities, language access profile, and exposure to language models in various contexts.

Assessment Considerations—How to Assess and What to Keep in Mind

Assessment tools and techniques are culturally, linguistically, and developmentally appropriate and vary based upon the goals of assessment. Assessment results are considered within the context of a child’s foundational experiences, cultural orientation, languages and communication systems, sensory access, educational background, and family/care partner priorities and concerns. In some cases, for DHH children acquiring more than one spoken and/or signed languages, bilingual/multilingual or bimodal/multimodal development is addressed and monitored during service delivery and educational planning (ASHA, 2013; Bradham & Houston, 2015; Douglas, 2015; JCIH, 2019; Pizzo & Chilvers, 2016, 2019).

Audiologists and SLPs are mindful of the following:

• consider the duration of time a child has used all relevant language(s), forms of language, and communication systems (e.g., spoken, signed, cued, written) being assessed and their proficiency with each in different environments (M. L. Hall, 2020; Pizzo & Chilvers, 2016, 2019)
• examine a child’s audiogram, speech recognition, and functional listening skills; perform function checks of any technologies; and/or confirm necessary visual access prior to assessment to ensure equitable, valid, and reliable results
• recognize the impact of acoustics and a child’s hearing age, the age at which a child begins to consistently use hearing technology such as hearing aids and cochlear implants, on access to test stimuli, test administration, and test interpretation (Bradham & Houston, 2015; Perigoe & Paterson, 2013; Pizzo & Chilvers, 2019)
• collaborate with qualified interpreters/transliterators or ancillary examiners (e.g., teachers of ELLs, ASL specialists, teachers of the Deaf) when not proficient in the child’s or family’s language(s) and/or communication system(s) (ASHA, 2013; M. L. Hall et al., 2019; M. S. Miller et al., 2015; NASDSE, 2018)
• take caution to differentiate a difference or delay from a disorder, especially with signing children, by considering assessment results from all forms of language and communication systems used by the child (M. S. Miller et al., 2015)
• use criterion-referenced tests; language sampling analysis; ethnographic interviewing; and authentic and dynamic assessments to examine conversational proficiency and aspects of speech, language, and cognitive functioning in daily activities that norm-referenced assessments may not be sensitive enough to detect (Blaiser & Shannahan, 2018; Mann et al., 2014; Werfel & Douglas, 2017)
• consider video recording, particularly when using sign language or visual communication systems and/or measuring intelligibility
• describe any adjustments made to the assessment process/environment and document how accommodations and modifications for language, communication, or sensory needs may create nonstandard administration and interpretation of results (e.g., spoken English assessments interpreted into ASL, certain test stimuli eliminated due to access concerns)
• document any adaptations to standardized assessments to allow for reassessment using the same (similar) procedures (i.e., to better ensure test–retest reliability)
• terminate speech-language assessment when methods are determined to be inappropriate and/or the child is unable to participate or reliably access the stimuli even with accommodations or modifications (Pizzo & Chilvers, 2019)

See Assessment Tools, Techniques, and Data Sources and Dynamic Assessment.

Assessment Challenges

Assessment of children who are identified as DHH is a complex process that challenges many traditional methods of evaluating language, literacy, speech, and cognition. DHH children often use a wide variety of languages, communication systems, and/or technologies, which may vary based on context and environment. At least 40% have more complex needs due to co-occurring diagnoses (e.g., cytomegalovirus, intellectual disability, cerebral palsy, autism). This diversity can make it hard to determine which languages/systems to include in assessment, how to evaluate their function, and what tools to use to minimize barriers and increase reliability (Caemmerer et al., 2016; Pizzo & Chilvers, 2019). Other assessment challenges are as follows:

• It can be difficult to differentially diagnose a language delay from a language disorder. Clear information about the extent of a child’s access to early linguistic input can assist with this (De Anda et al., 2016; M. L. Hall, 2020; M. L. Hall & De Anda, 2021; Holcomb & Lawyer, 2020; Rufsvold et al., 2018).
• Few standardized tests for spoken/written language include DHH children in their sample populations/norms. Some test items based on auditory concepts may not be accessible, and others may have no equivalent interpretation in sign language (M. S. Miller et al., 2015).
• Although assessments normed on typically hearing children are often used with DHH children, particularly those who use spoken language, standardized scores are reported with additional context statements.
• Reliable and valid assessments of signed language proficiency are limited, and qualified professionals with the competence to conduct them directly with the child are uncommon (Beal-Alvarez, 2016; Caselli et al., 2020; Enns et al., 2016; Henner et al., 2018; Pizzo & Chilvers, 2019; Simms et al., 2013).
• Language accommodations, test modifications, and technologies do not always eliminate barriers or optimize students’ performance on standardized assessments, depending on the skills the tests are designed to assess and how test items are constructed and administered (Higgins et al., 2016).
• Equipment may need troubleshooting during assessment.

Goals, Skilled Services, and Supports

Audiologists, SLPs, and related service professionals provide complementary, interrelated, and, at times, overlapping services to help children who are identified as DHH acquire, maintain, reestablish, and/or improve current speech, language, listening, and cognitive-communication skills. Evidence comparing services and supports specifically for DHH children is limited. Some DHH children may benefit from adaptations to evidence-based interventions developed for hearing children.

General Considerations

Service delivery for prelingually DHH children has shifted more toward proactive developmental approaches because of advancements in EHDI systems and technology. Goals, services, and supports emphasize early language intervention across contexts to minimize communication delays and disorders. Programming considers individualized needs as outlined above in the Guiding Principles for Development of Linguistic and Communicative Competence section (ASHA, 2013; JCIH, 2019; Lederberg et al., 2013; Moeller et al., 2016).

Establishing strong language foundations early promotes the development of literacy, cognitive–linguistic, and social skills. The benefits of early intervention can only be sustained when supports continue throughout the school years. If developmental milestones are not being met, timely modifications to language and communication plans may be necessary (JCIH, 2019; Lederberg et al., 2013; Moeller et al., 2013, 2016; NASDSE, 2018).

Children may encounter new difficulties when advancing through school as cognitive, communication, academic, and social demands increase. Continue to monitor language and communication competence to detect these challenges early. Even if children do not require persistent service delivery throughout school, they may need services later as new challenges arise. Audiologists and SLPs encourage families/care partners to seek services when they have any concerns about their child’s progress or hearing status.

Counseling

The child, their family/care partners, and other professionals working with the child benefit from informational counseling. Topics and issues addressed may include the following:

• audiologic information
• impact of language exposure and access on child development
• accepting their child’s deafness
• assisting with networking and making connections with other DHH people (e.g., adult role models, other families with DHH members) through various outreach organization and mentoring programs
• desired language outcomes
• individualized language and communication planning
  • education and/or training, as applicable, in the full spectrum of language, communication, and academic opportunities available to develop the skills necessary to communicate functionally across various contexts
  • use and care of hearing technologies, as applicable, including daily functional listening checks, visual inspection, troubleshooting, and data logging
  • communication strategies training (e.g., facilitative and repair techniques)
  • availability of and the need for other assistive technologies and accommodations, such as alerting and safety devices, telecommunications services, interpreters, transliterators, and captioning services
  • methods used to gather data for assessment and progress monitoring
• realistic expectations for services, educational programing, and transition planning
• coping and compensatory strategies
• self-advocacy (ASHA, 2008)

See ASHA’s Patient Education Handouts—Audiology Information Series for resources that may be helpful during counseling. For more information, see the ASHA Practice Portal pages on Counseling in Audiology and Speech-Language Pathology and Cultural Responsiveness.

Consider referrals for additional counseling by a mental health provider (e.g., school counselor, psychologist), support groups, and other community resources if necessary (Dammeyer et al., 2018; Fitzpatrick et al., 2008; Humphries et al., 2019; Theunissen et al., 2014).

Listening and Spoken Language

Most DHH children are born to typically hearing families who often have listening and spoken language as a goal (White, 2018). Children who become DHH after acquiring language may already have enough of a listening and spoken language foundation to be successful communicators and learners in an auditory environment given that they receive appropriate supports post-onset of hearing loss (Humphries et al., 2019). With early identification and advances in hearing technology, some children with different hearing levels can now access auditory input and work toward listening, spoken, and written language outcomes consistent with expected developmental milestones (Bowers, 2017; Lederberg et al., 2013, 2019). Effective ongoing audiologic management, consistent use of well-fit and maintained hearing technology, and appropriate family-centered intervention are essential for these outcomes to occur (Costa et al., 2019; Cruz et al., 2013; Moeller et al., 2016; Rosenzweig, 2017; Soman & Nevins, 2018; Tomblin et al., 2014, 2015).

Listening and spoken language development can occur in auditory-only contexts or with multimodal (e.g., visual, tactile) supports (Gibbons & Szarkowski, 2019; Knoors, 2016; Roberts & Hampton, 2018; J. A. Scott & Dostal, 2019). The goal of listening and spoken language development is to ensure auditory access and/or functional listening skills.

Auditory Skill Development

The goal of auditory skill development, or auditory training, is to develop a child’s “ability to recognize speech using the auditory signal and to interpret auditory experiences” (Tye-Murray, 2020, p. 102). To facilitate auditory skill development, families/care partners and service providers must first ensure hearing technology function by examining equipment integrity and performing daily listening checks (e.g., Ling Six Sound Check [Ling, 1976]; Low-, Mid-, and High-Frequency (LMH) Test [Madell & Hewitt, 2022]). 

Auditory skill development can occur in many contexts. Training for younger children who have not yet fully developed listening and language skills tends to consist of a continuum of skills and may include the following types of activities per Erber (1982):

• awareness/detection (e.g., play musical chairs to determine presence or absence of sound)
• discrimination (e.g., use minimal pairs to distinguish sounds as same or different)
• identification (e.g., label stimuli by listening for color names pointing to the corresponding color)
• comprehension (e.g., ask child to indicate understanding by answering questions; use barrier games)

Erber’s model listed above provides a framework for developing a vast array of auditory skills ranging from turning to sounds in the environment to more complex skills (e.g., comprehending a conversation on television or on a telephone). Informal training can be encouraged in daily routines through strategies such as calling attention to environmental sounds, using acoustic highlighting, or recasting and expansion or extension of language during conversations in the home. When using acoustic highlighting, one uses vocal emphasis to draw attention to a target sound, word, phrase, or grammatical structure (Fickenscher, 2022). Expansion involves repeating an utterance by a child using correct adult syntax and semantics, whereas extension of the child’s utterance adds additional words and information to the child’s utterance (MacIver-Lux et al., 2020). Children can also engage in more formal independent web-based training programs as they grow (Tye-Murray, 2020).

Auditory-Verbal Therapy/Auditory-Verbal Education

Auditory-Verbal Therapy (AVT) focuses on guiding and coaching families/care partners to be the primary facilitators of their children’s listening and spoken language (LSL) development. AVT emphasizes spoken language acquisition exclusively through listening using hearing technologies such as cochlear implants. Auditory-Verbal Education (AVE) is also part of listening and spoken language training. AVE teaches DHH children to listen and talk exclusively through listening and spoken language instruction and encourages auditory stimulation and mainstream education with peers who have typical hearing as early as possible (AG Bell Academy for Listening and Spoken Language, 2017). The desired outcome of AVT is spoken language through audition, so formal signed systems and speechreading are not directly taught (Estabrooks et al., 2016).

The AG Bell Academy for Listening and Spoken Language (2007) has two sets of principles that outline the practice of AVT and AVE in more detail. See Principles of Certified LSL Specialists.

Professional training and certification in these principles is available for those who serve DHH children primarily using listening and spoken language for communication. Having qualified clinicians with sufficient knowledge and background in this approach is necessary to ensure quality service delivery and functional AVT outcomes.

Auditory-Oral Methods

Auditory-Oral programming also supports family-centered practices to develop LSL skills. However, unlike AVT, it does not teach DHH children to listen and talk exclusively through listening and spoken language instruction. Goals target spoken language development through attention/listening/auditory skills training as well as visual or tactile cues, facial expressions, and natural gestures. A formal signed language or Manually Coded English systems are not utilized because the goal is spoken language (Demers & Bergeron, 2019; Dettman et al., 2013; Thomas & Zwolan, 2019; Tye-Murray, 2020). Families/care partners collaborate with the child’s service providers to carry over strategies and techniques for developing listening, speechreading, spoken language, and cognitive skills in an oral learning environment.

Speechreading

Speechreading addresses speech recognition by integrating auditory and visual information from movements of the face and mouth, as well as supportive gestures (Seal et al., 2013). It differs from lipreading, which relies only on visual cues from the speaker’s face. While lipreading and speechreading programs were historically an important part of Auditory-Oral communication training, advancements in listening technologies and questions about the efficacy of teaching these techniques have led to decreased emphasis on their use in service delivery (Tye-Murray, 2020). Service delivery more often emphasizes communication partner training (e.g., speech rate, prosody, facial characteristics, message complexity/context) and environmental modifications (e.g., sight lines, room acoustics, background noise). However, some DHH individuals also use lipreading and speechreading to support communication exchanges.

Speech and Voice Production

Speech recognition abilities influence speech and voice production (Kishon-Rabin et al., 2002). Consider consistency of hearing technology use and its benefit when determining age-appropriate speech targets (Perigoe & Paterson, 2013). Goals often focus on consonant distortions, substitutions, and omissions; phonological processes; and vowel production errors. Common targets may include

• cluster reduction;
• devoicing, especially for voiced sounds and high-frequency fricatives;
• diphthongizations;
• final-consonant deletion;
• nasalizations;
• omission of unstressed syllables;
• stopping;
• suprasegmental features of speech production (e.g., appropriate loudness level, pitch, and intonation); and
• vowel neutralization.

Multiple factors impact the approach to articulation and phonological intervention, including age, audibility, stimulability, cognitive–linguistic function, and access to conversational speech models. Self-monitoring spoken language through listening is critical for children to make gains in speech intelligibility at the conversational level (Moeller et al., 2016; Tye-Murray, 2020).

The impact of voice quality on speech intelligibility and social communication is also an important consideration. Some children may not have the auditory access to monitor rate, rhythm, loudness, pitch, intonation, respiration, and resonance of their own speech and voice. Visual, tactile/kinesthetic, and proprioceptive cues can be effective strategies instead. Pairing phonation and articulation goals with these vocal techniques can help improve speech quality and intelligibility (Coelho et al., 2015).

Progress in developing communicative competence using speech is regularly assessed, and ongoing collaboration with audiology is essential to maximize the child’s access to speech information. Consider additional language and communication strategies, technologies, and/or supports if the child is not meeting speech and articulation milestones.

Signed Language

DHH children develop sign language on the same trajectory as hearing children develop spoken language, unless they have a language disorder, lack access to a language-rich environment, or experience a period of language delay or deprivation (M. L. Hall et al., 2019; W. C. Hall et al., 2017). DHH children of deaf parents typically have consistent exposure to language from birth. However, for DHH children of hearing parents, sign language development depends on the age and consistency of quality exposure to a visually accessible first language (Beal-Alvarez, 2014; Marschark et al., 2006; Spencer & Marschark, 2010). Families/care partners require different kinds of supports to provide their children with access to signed language, such as fluent ASL models (e.g., via Deaf mentors, ASL specialists, video narratives) to address manual babbling interactions, early sign vocabulary development, grammatically correct structure, and expression and/or comprehension of more advanced linguistic features (Beal-Alvarez, 2014; Lederberg et al., 2013).

Signed language disorders can exist among DHH children despite early exposure to a signed language, including echolalia, hand/palm orientation errors, and comprehension difficulties (Cripps et al., 2016; Herman et al., 2014; Marshall et al., 2013; Shield et al., 2017; Shield & Meier, 2012; Woll & Morgan, 2012). Additionally, children who experience a period of incomplete language access before gaining access to a signed language often exhibit distinctively disordered characteristics of language deprivation (Cheng et al., 2019; Mayberry & Klunder, 2018). Atypical signed language acquisition and signed language disorders involving aphasia, disfluency, and specific language impairment exist, but there are few evidence-based interventions available. SLPs have reported developing their own intervention strategies such as modeling, correction, and self-reflection to address syntax, semantics, morphology, narrative abilities, use of signing space and nonmanual signals, articulation of signs, and processing of fingerspelling (Quinto-Pozos, 2014; Quinto-Pozos & Cooley, 2020; Quinto-Pozos et al., 2011). Consultation with DHH ASL specialists, when possible, can address these issues using a collaborative approach.

SLPs document children’s receptive and expressive sign language development and target constructs the children do not yet understand or produce. Collaborating with a signed language specialist (e.g., ASL specialist or teacher of the Deaf) is essential if the SLP does not possess the level of sign language proficiency to assess and treat signed language disorders or distinguish a difference from a disorder (Cripps et al., 2016).

Bimodal–Bilingual (Signed and Spoken Language)

Bimodal–bilingual strategies focus on providing children with strong foundations in both signed and spoken languages to promote linguistic and communication access and foster academic success (Chen Pichler et al., 2014; Davidson et al., 2014; Mitchiner, 2015; Mitchiner et al., 2012; Nussbaum, Scott, & Simms, 2012; Swanwick, 2016). Foundations for bimodal–bilingual strategies are developed by

• working with families to fully develop both signed and spoken languages as separate languages and modalities using the strategy of language separation (i.e., only one language is used at a time; no simultaneous communication);
• offering accessible sign language curricula to families/care partners to facilitate visual interactions with their child;
• training families/care partners in techniques for listening and spoken language development;
• encouraging consistent use of auditory skills/speech/spoken language and signed language separately in the child’s day, allowing for exposure to the same vocabulary and concepts in both languages;
• making associations between signed, spoken, and written languages using the following strategies:
  • sandwiching: speaking it–signing it–speaking it, or the reverse (signing it–speaking it–signing it);
  • chaining: signing it–speaking it, fingerspelling it, using graphic support; and
  • providing explicit associations between the signed and spoken/written languages (e.g., explaining, “This is what it looks like in ASL; this is how it is spoken or written in English”); and
• facilitating early language acquisition by connecting families/care partners with DHH adults trained to help them learn visual and/or spoken language strategies.

Strategies in a bimodal–bilingual plan reflect individualized child/family/care partner goals and the child’s current level of function and communication preference (Gárate, 2014; Hamilton & Clarke, 2020; Pittman et al., 2016). Goals for communicating in both languages consider the child’s various settings and communication partners, facilitating movement along a receptive and expressive auditory–visual continuum as required (Nussbaum, Waddy-Smith, & Doyle, 2012; Swanwick, 2016).

Visual Systems and Multimodal Communication

Other multimodal communication supports may be useful for those not targeting complete bimodal–bilingual language development (e.g., those with multiple disabilities or later onset progressive hearing loss). Supporting spoken language and literacy may involve training children and families/care partners to use one or more of the following systems:

• Manually Coded English/sign systems
• cued speech
• visual phonics
• AAC

Please see Languages and Communication Systems for Deaf and Hard of Hearing Children for further information.

It is important to provide children and families/care partners with models who use various combined languages and communication systems to help guide acquisition and demonstrate how they might adjust their communication in various contexts (LaSasso et al., 2010; Lenihan & Gardiner-Walsh, 2020; Meinzen-Derr, 2018; Meinzen-Derr et al., 2019; Narr & Cawthon, 2011; NASDSE, 2018; Nussbaum & Scott, 2011; P. V. Paul, 2009; Pittman et al., 2016; Schick, 2011; J. A. Scott & Dostal, 2019; Singer et al., 2020).

See ASHA’s Practice Portal page on Augmentative and Alternative Communication.

Literacy

Developing literacy skills has been an area of challenge for many DHH children (Easterbrooks & Beal-Alvarez, 2013; Hayes et al., 2014; Lederberg et al., 2013; Marschark et al., 2015; Runnion & Gray, 2019; Wolsey et al., 2018). Children who do not have access to sound and/or use sign language are often learning to read and write a language that differs from their own (i.e., spoken phonological representations of words and print do not correspond to the phonemes of their signs). They may learn to identify words differently from hearing children or DHH children who acquire listening and spoken language skills (e.g., via fingerspelling; Lederberg et al., 2013, 2019).

Regardless of the language(s) used, children who are identified as DHH need constant exposure to reading to promote acquisition of literacy. Print concept knowledge, alphabet knowledge, phonological awareness, and receptive and expressive language skills are critical to prepare children for later conventional reading instruction targeting decoding, fluency, and reading comprehension (Flexer, 2017; Runnion & Gray, 2019). Strategies and programs that have been used to support the process of learning to read and write in this population include the following:

• literacy-rich play with manipulatives from stories (Easterbrooks et al., 2010)
• shared reading/dialogic reading, where families/care partners and teachers also receive support from DHH adults in interactive techniques such as signing books, commenting, questioning, prompting, and expansion (DesJardin et al., 2014; E. M. Miller et al., 2013; Runnion & Gray, 2019; Schleper, 1995; Trussell et al., 2018)
• explicit instruction in phonics (e.g., how graphemes map onto phonemes), phonological awareness (e.g., rhyme and phoneme segmentation), alphabet knowledge, and vocabulary/oral language skills using
  • visual support of tools (e.g., Cued Speech or Visual Phonics)
  • targeted early literacy curricula (e.g., Foundations for Literacy), and
  • semantic associations/cues

  (Flexer, 2017; Gilliver et al., 2016; Hayes et al., 2014; LaSasso et al., 2010; Lederberg et al., 2014; Lund & Douglas, 2016; E. M. Miller et al., 2013; Narr, 2008; Nussbaum, Waddy-Smith, & Doyle, 2012; Runnion & Gray, 2019; Trussell et al., 2018)

• multimodal frameworks using visual language, visual learning, and visual displays, such as
  • drawing/labeling pictures with printed words, phrases, and sentences;
  • fingerspelling and visual phonology;
  • ASL and English bilingual strategies for social and academic literacy;
  • posted classroom schedules, routines, assignments, and vocabulary; and
  • electronic whiteboards and captioned media

  (Andrews et al., 2016; Dostal et al., 2017; Gárate, 2014; Lederberg et al., 2019; Nussbaum, Waddy-Smith, & Doyle, 2012; J. A. Scott & Dostal, 2019; Wolsey et al., 2018)

• explicit instruction in higher level literacy skills
  • restating, paraphrasing, or summarizing information read or new terms/concepts introduced
  • making inferences, recognizing figurative language and multiple word meanings, organizing narratives, and discussing characteristics of a good story
  • integrating services within language arts classes/curriculum and social literacy contexts

  (Albertini et al., 2016; Gárate, 2014; Nussbaum, Waddy-Smith, & Doyle, 2012)

These visual, tactile, kinesthetic, and auditory instructional strategies can be implemented and adjusted according to the needs of each child.

For more information, see ASHA’s Practice Portal page on Written Language Disorders and Hearing First’s Start With the Brain and Connect the Dots: Supporting Children Who Are Deaf or Hard of Hearing to Develop Literacy Through Listening and Spoken Language.

Cognitive and Social Skills

DHH children with autism, intellectual disability, or certain genetic syndromes may have cognitive and social communication difficulties. Even without these diagnoses, DHH children have an elevated risk of developing cognitive and social challenges (e.g., isolation, bullying) due to periods of linguistic and cognitive deprivation and sensory fatigue (Kouwenberg et al., 2012; Warner-Czyz, 2018). Executive function, theory of mind, and social communication appear to correspond with linguistic and communicative competence in children who are identified as DHH. Strategies to support executive function challenges with attention, working memory, and inhibition can help provide the foundation for planning, problem solving, and organization (Knoors & Marschark, 2020; Kronenberger et al., 2014, 2020; McConkey Robbins & Kronenberger, 2021; Szarkowski et al., 2020; Yoshinaga-Itano et al., 2020).

Theory-of-mind training is often addressed in combination with social skills development because both have considerable effects on social interactions and peer relationships (Knoors & Marschark, 2020; Westby, 2017). Skilled services and supports for DHH children tend to focus most on

• addressing social nuances of interactions and game-playing via role play;
• recognizing others’ expectations, experiences, viewpoints, and emotions or having empathy;
• initiating interactions, managing joint attention, and recognizing nonverbal cues;
• turn-taking, topic maintenance, asking/answering questions, and repairing conversational breakdowns;
• understanding and using figurative language, humor, deception, and sarcasm;
• self-evaluation, making choices, and understanding when to use cues/compensatory strategies; and
• training communication partners to enhance the quantity and quality of interactions, increase social integration, and facilitate incidental learning (Goberis et al., 2012; Szarkowski, 2020; Westby, 2017; Yoshinaga-Itano et al., 2020).

Some differences in perspective-taking and pragmatic use of language may reflect variations in culturally specific social norms in hearing and Deaf communities, not disordered language (R. Paul et al., 2020).

Assistive Technologies, Accommodations, and Strategies

Various technologies, accommodations, and strategies are available to remove barriers and provide equitable access based on a child’s individual needs. DHH children need full and consistent access to language, communication, and learning across contexts to have the same opportunity to acquire information and participate in activities as their hearing peers. Strategies to address accessibility, visual fatigue, and listening demands throughout a child’s day need to be considered when developing individualized family service plans, Individualized Education Programs (IEP), and 504 plans (Bess et al., 2020; Camarata et al., 2018; Spangler & Flexer, 2015).

Visual Access

• adequate lighting, nonglare lighting, and window coverings to facilitate visual attention and reduce fatigue
• solid, clean backgrounds to support speechreading, cued speech, and sign language use
• clear sight lines and strategic seating toward speakers, interpreters/transliterators, text, and video
• visual supports such as
  • printed schedules/announcements,
  • high-contrast or large-print graphics,
  • pictures, and
  • copies of notes and slides
• visual alerting and signaling devices to indicate bells or alarms, transition between activities or to gain attention
• captioned media, Communication Access Realtime Translation (CART), telecommunications relay, and other speech-to-text services
• scheduled visual breaks throughout the day

Auditory Access

• seating away from environmental noises (e.g., busy streets, air-conditioning unit)
• reduction of background noise that may interfere with a student’s ability to hear speech (e.g., chairs moving, music)
• sound-absorbing materials such as
  • acoustic ceiling tiles/wall coverings,
  • carpets,
  • window treatments, and
  • rubber guards around doors
• closed windows and doors and classrooms with walls
• listening breaks during the day to avoid overload
• assistive listening technology such as
  • frequency modulation (FM) system
  • digital modulation (DM) system, and
  • classroom audio distribution system (CADS)

Educational Access

• alerting cues to listen/listen for meaning
• direct communication with teacher and peers
• “one speaker at a time” rule, with clarity and natural rate/volume, facing the child
• comprehension checks with open-ended questions, rephrasing, and repetition
• close proximity to auditory signal and visual cues
• acoustic highlighting to enhance auditory clarity of spoken language (e.g., using suprasegmentals)
• requests to repeat or confirm information
• pre-teaching new language/academic concepts and sharing outlines/vocabulary ahead of lessons
• note-taking strategies
• training/troubleshooting guidelines for staff regarding accessibility accommodations, any auditory technology, role of interpreter/transliterator, and emergency plans
• functional connectivity between the child’s personal technology and educational technology
• testing modifications

Audiologists and SLPs work to promote a child’s self-advocacy with respect to use of these technologies, accommodations, and strategies and monitor their access needs on an ongoing basis in various contexts to make necessary changes (Laurent Clerc National Deaf Education Center & Boston Children’s Hospital, 2015; Spangler & Flexer, 2015; Starr, 2017).

See ASHA’s Practice Portal pages on Classroom Acoustics; Cochlear Implants; Collaborating With Interpreters, Transliterators, and Translators; and Hearing Aids for Children. See also supporting success for children with hearing loss.

Transition Planning and Self-Determination

When transitioning from early intervention to school-based services, any communication strategies, supports, and technologies the child uses must be documented and monitored to ensure proper implementation and ongoing language development and learning. Please see the JCIH Position Statement (2019, pp. 27–28) and ASHA’s resource on IDEA Part C: Transitions for further information.

Effective transition planning between schools and postsecondary settings is essential to prepare students for academic and vocational success as well as independent living. Some DHH students may have gaps in functional social, communication, and life skills due to challenges with incidental learning and access to language, even if they are on target academically (NASDSE, 2018). Literacy, self-advocacy, reasoning and problem solving, accommodation training, college or career planning/readiness, and independent living skills are important transitional competencies and need to be addressed by families/care partners and professionals with knowledge of the student’s language and communication needs.

Audiologists, SLPs, and other team members can also support development of self-determination and independence by incorporating the following items into their treatment plans:

• Explicitly teaching skills such as
  • autonomy,
  • self-awareness,
  • emotional intelligence,
  • goal setting,
  • problem solving, and
  • taking responsibility for communication access accommodations (e.g., use of interpreters, captioning, hearing technologies).
• Connecting academics to personal goals.
• Planning opportunities to engage the child in
  • controlling and manipulating their surroundings,
  • assessing options,
  • deciding actions including involvement in the IEP/504 process, and
  • accepting consequences.
• Role-playing self-advocacy scenarios before leaving high school so they can independently negotiate for postsecondary plans and needed services or accommodations in those settings.
• Training families/care partners in strategies to support development of these skills in their children (Laurent Clerc National Deaf Education Center & Boston Children’s Hospital, 2015; Luckner & Becker, 2013; Luckner & Sebald, 2013; Millen et al., 2019; NASDSE, 2018).

Services and supports addressing self-advocacy and self-determination facilitate transitions for DHH children, help them to get their needs met, and foster positive language and communication outcomes throughout their lives.

See ASHA’s Postsecondary Transition Planning page and the National Deaf Center on Post-Secondary Outcomes for more information.

ASHA Resources

• American Sign Language (ASL)
• Audiologic Issues in CHARGE Syndrome
• Child Aural/Audiologic Rehabilitation
• Cochlear Implants in the Classroom
• Collaboration and Teaming
• Common Core State Standards (CCSS) and Students With Hearing Loss: Important Role for Educational Audiologists
• Federal/State Laws and Regulations Related to Service Provision for Children Who Are Deaf and Hard of Hearing (DHH)
• Guidelines for Audiologists Providing Informational and Adjustment Counseling to Families of Infants and Young Children With Hearing Loss Birth to 5 Years of Age
• Guidelines for Fitting and Monitoring FM Systems
• Hearing Loss Organizations and Associations
• Hearing-Related Topics: Terminology Guidance
• IDEA Part C: Implications for Audiologists and Speech-Language Pathologists Who Provide Services for Infants and Toddlers with Hearing Loss and Their Families
• Interprofessional Education/Interprofessional Practice (IPE/IPP)
• Knowledge and Skills Required for the Practice of Audiologic/Aural Rehabilitation
• Languages and Communication Systems for Deaf and Hard of Hearing Children
• Natural Environments for Infants and Toddlers Who Are Deaf or Hard of Hearing and Their Families
• Service Provision to Children Who Are Deaf and Hard of Hearing, Birth to 36 Months
• Students Who are Deaf or Hard of Hearing in the School Setting
• Teens and Young Adults: Achievement With Hearing Loss
• Tips for Helping Students With Hearing Loss in Virtual and In-Person Learning Settings

Other Resources

• Alexander Graham Bell Academy for Listening and Spoken Language
• Alexander Graham Bell Association for the Deaf and Hard of Hearing
• American Cochlear Implant Alliance
• American Society for Deaf Children
• ASL Connect
• ASL Content Standards Kindergarten–Grade 12
• Baby Hearing: Parenting a Child who is Deaf or Hard of Hearing
• BEGINNINGS for Parents of Children who are Deaf or Hard of Hearing
• Boys Town Center for Childhood Deafness, Language and Learning
• Conference of Educational Administrators of Schools and Programs for the Deaf
• Council for Exceptional Children – Division for Communication, Language, and Deaf/Hard of Hearing
• Educational Audiology Association
• EHDI-PALS
• Hands & Voices
• Hands & Voices Family Leadership in Language and Learning Center
• Hear to Learn
• Hearing First
• Laurent Clerc National Deaf Education Center
• Language First
• Learning to Listen: Sounds and Phrases
• Listening Together
• Longitudinal Outcomes of Children with Hearing Impairment (LOCHI)
• Making a Plan for Your Child: IFSP Considerations for Children who are Deaf and Hard of Hearing [PDF]
• National Association of the Deaf
• National Center for Hearing Assessment and Management
• National Cued Speech Association
• National Deaf Center on Postsecondary Outcomes
• Opening Doors: Technology and Communication Options for Children with Hearing Loss [PDF]
• OPTION Schools
• Outcomes of Children with Hearing Loss Study
• Raising and Educating Deaf Children
• SKI-HI Deaf Mentor Program
• Supporting Students who are Hard of Hearing: Promoting a Positive Educational Experience [PDF]
• Supporting Success For Children with Hearing Loss
• Supporting Students who are Deaf and Hard of Hearing: Shared and Suggested Roles of Educational Audiologists, Teachers of the Deaf and Hard of Hearing, and Speech-Language Pathologists [PDF]
• Visual Language and Visual Learning Center (VL2)

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Yoshinaga-Itano, C., Sedey, A. L., Wiggin, M., & Mason, C. A. (2018). Language outcomes improved through early hearing detection and earlier cochlear implantation. Otology & Neurotology, 39(10), 1256–1263. https://doi.org/10.1097/MAO.0000000000001976

Acknowledgments

Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Language and Communication of Deaf and Hard of Hearing Children page:

• Kristi Blaiser, PhD, CCC-SLP
• Becky Clem, MA, CCC-SLP
• Jennifer Gaston, AuD, CCC-A
• Claire Lombardo Miller, MS, CCC-SLP, NIC
• Debra Nussbaum, MA
• Maryam Salehomoum, PhD, CCC-SLP
• Kimberly Sanzo, MS, CCC-SLP
• Derek Stiles, PhD, CCC-A
• Andrea Warner-Czyz, PhD, CCC-A
• Razi Zarchy, MS, CCC-SLP
• Lindsay Zombek, MS, CCC-SLP

In addition, ASHA thanks the members of the Ad Hoc Committee, whose work was foundational to the development of this content. Members of the committee were Pam Mason (ex officio), Allan O. Diefendorf (chair), Kathryn L. Beauchaine, Diane L. Sabo, and Anne Marie Tharpe. Roberta B. Aungst, vice president for professional practices in audiology (2004–2006), served as monitoring vice president.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association. (n.d.). Language and Communication of Deaf and Hard of Hearing Children [Practice Portal]. Retrieved month, day, year, from www.asha.org/practice-portal/professional-issues/language-communication-deaf-hard-of-hearing-children/.