COMMUNICATION (RE)HABILITATION FOR THE HEARING IMPAIRED:

A CLINICAL OVERVIEW

Susan H. Brainerd
University of Western Ontario

ABSTRACT
A review is presented of selected programs and procedures appropriate to employ in
communication (re)habilitation therapy for pre-school, school-aged and adult hearing
impaired clients. It is suggested that comprehensive, individualized programming can be
facilitated through reference to a flexible model of normal communication.

A diversity of communicative disorders are exhibited within the population of

individuals who have hearing impairments. Auditory reception, speech production and
language acquisition disabilities are expected in varying degrees and combinations
depending upon the site of lesion in the auditory pathway, the extent of damage or
involvement, the age of the individual at the onset of the impairment and the presence of
concomitant incapacities. Due to these multivarious consequences, clinicians charged
with developing and/or maintaining'communication skills in hearing impaired clients
require knowledge of a wide variety of specialized intervention techniques.
To ensure that (re)habilitation programs designed for hearing impaired clients are
comprehensive, a model of normal communication is a recommended reference.
Sanders' (1976) model appears well suited to this task since it offers a guide to
comprehensive yet flexible intervention programming. (Re)habilitation programs based
on this model would include evaluation and development, as needed, of clients' language
systems, central processing abilities, and methods for both transmitting and receiving
information. According to Sanders' model, communicative information may be
equivalently relayed through alternative channels, indicating a need to assess clients'
abilities to employ a variety of transmission forms (including speaking, writing and
signing) and receptive sensory capacities (including auditory. visual, tactile and
kinesthetic).
Contemporary communication (re)habilitation programs for hearing impaired clients
are developed on an individualized basis and evolve from a critical and continuous
perusal of available literature. To assist clinicians in this necessary review process, a
survey of current intervention strategies is presented below according to age group
relevance.

Habilitation for Preschool Clients

Opt imal habilitation programs for preschool hearing impaired clients follow a
multidisciplinary plan designed to fulfili each child's educational, medical and social
needs. Interdisciplinary cooperation particularly is required for meeting the special
considerations of mUltiply handicapped children, a conservatively estimated 30% of the
hearing impaired popUlation (Bolton, 1972). Comprehensive team membership
normally includes both consulting and continuing professionals. Continuing team
membership may include a program coordinator, a teacher of the deaf, a
nursery I kindergarten teacher, an educational audiologist, a child psychologist, a speech
a nd language thera pis!. a ch ild development specialist, a social worker, a parent advisor,
a health representative, a physical therapist and an occupational therapist (Northcott,
1977, p. 10). As part of the occupational therapy evaluation, administration of the

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HUMAN COMMUNICATION, SPRING 1978
Southern California Sensory Integration Test (based on Ayers, 1972) warrants special
recommendation as soon as age appropriateness is reached. This assessment of sensory
functions (including vestibular, visual and tactile perceptions) can assist significantly in
the selection of efficient sensory channels for communication skills development.

Parents of preschool hearing impaired children can be active, valuable members of the
habilitation team. With proper instruction, many parents can serve as their child's
primary habilitator. Parent training programs may follow either clinic or home based
models with instruction offered either individually or in groups. Baker (1976) presents
guidelines for developing effective parent training programs. Cseful parent oriented
home programs employing a profile approach to assessment and training include the
Portage Project (Shearer and Shearer, 1976) and the READ Project (Baker and Heifetz,
1976). Both projects are appropriate for use with any developmentally delayed child.
Recent home based curriculum guides specific to the communication needs of the
preschool hearing impaired population have been developed by Alpiner, et al (1977),
Clark (1977) and Northcott (1977).

Currently, the initial communication skills method of choice for a majority of preschool
hearing impaired children is the unisensory (auditory) approach. This method was
popularized by Pollack (1970) as the "acoupedic approach" and it forms the basis for the
communication skills programs outlined in each of the curriculum guides cited above.
The auditory method requires early fitting and continuous use of amplification
throughout the child's waking hours, in addition to progression through structured
auditory developmental steps. Specific instruction is provided in awareness, discrimina-
tion, identification and comprehension of both speech and nonspeech (e.g.,
environmental) sounds. Practice also is given on distance hearing and localization (if the
child is binaurally aided). Optimal functioning of the amplification system(s), of course,
is mandatory. Ruben (1975) has developed one useful primer on daily hearing aid
maintenance and troubleshooting.

Progress through the auditory approach should be monitored regularly. Both Northcott
(1977, pp. 39-45) and Northern and Downs (1974, pp. 268-270) have developed scales
which may assist in predicting and evaluating such advancement. Northcott's Auditory
Objective Scale summarizes the acquisition of specified auditory and auditory-oral skills
by children in her preschool program. Auditory progress is reported in relation to both
severity of hearing loss and "hearing age", i.e., length of time amplification was worn,
Northern and Downs' Deafness Management Quotient attempts to predict potential for
success in an auditory program by weighing estimates of auditory thresholds,
intellectual capacity, central processing abilities, family support and socio-economic
status. Available recommendations regarding the minimum length of time an auditory
approach should be followed prior to evaluation for multisensory training vary from 6
months (Clark, 1977, p. 275) to 1-2 years (Calvert and Silverman, 1975, p. 169) after full
time hearing aid usage has been achieved.

Satisfactory progress through the auditory approach must include demonstration of

adequate speech and language development in addition to auditory skill achievement.
Prescriptive language evaluations appropriate for the prechool hearing impaired
population include the Uzgiris and Hunt (1975) preverbal language scales the Bloom
and Lahey (1978) form by content analyses. Ling (1976) has outlined a useful evaluative
and instructional program for speech skill acquisition. This program is discussed in
greater detail below.

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 BRAINERD: COMMUNICATION (RE)HABILlTATlON

Nonauditory instructional procedures should be added to habilitation programs for

preschool hearing impaired clients who are not progressing satisfactorily through an
auditory approach. Visual, tactile and/ or kinesthetic cues comprise the most common
supplements. Traditionally, clinicians have been encouraged to employ, as needed, any
available nonauditory techniques with the exception of manual communication.
Modification of this attitude in recognition of manual communication as an effective
habilitation tool is recommended at the present time (e.g., by Brainerd, 1976; Moores,
1974; and Wilbur, 1976). The philosophy of incorporating appropriate aural, manual
and oral methodologies in order to ensure effective communication with and among
hearing impaired persons is referred to as Total Communcation.' Garretson (1976) and
Jordon, et al (1976) have verified the dramatic increase in adoption of the Total
Communication philosophy in educational programs for the hearing impaired over the
past ten years. Summaries of available manual comunication systems have been written
by Moores (1974) and Wilbur (1976), among others. According to a recent survey by
Jordan, et al (1976) Signing Exact English (G ustason, et a!, 1976) is the manual system
most commonly employed with preschool hearing impaired children.

(Re)Habilitation for School Aged Clients

Appropriate educational placement is of prime (re)habilitative importance to school
aged hearing impaired children. A variety of specialized educational services are
required to fulfil! individual needs. Ross (1976a) recommends availability of both
aural/oral and total communication classes. Both Ross (1976a) and Leslie (1976)
recommend availability of alternative programs correlated with each of the seven levels
of the Cascade system of special education. The required alternatives include regular
class placements with or without supportive services, regular class placements with
supplemental instructional services, part-time special class attendance, full-time
special class attendance, enrollment in special schools, home bound programs and in-
struction in hospitals, residential or total care settings. Each child should be moved
away from full mainstreaming (Le., regular class placement) only as far as necessary
and he/ she should be moved towards full mainstreaming as quickly as possible.
1
Regular classroom assimilation is a goal of optimal communication (re)habilitatioll
programs for hearing impaired school aged children. Success at this level, however.
requires that a) the child be a good candidate for mainstreaming, b) the teacher and
classmates receive appropriate orientation information, and c) the classroom acoustics
are adequate for the use of amplification. Predictive evaluations of candidacy for
mainstreaming have been developed by Rudy and Nace (1973) and Ross (1976b). Rudy
and Nace's Transitional 1nstrument combines measures of intelligence, academic
achievement, hearing loss level and socialization skills to predict probable success in a
regular classroom. Ross' criteria for full mainstreaming include: ability to employ
audition as the main input channel for speech and language development, a minimum
delay of two - three years in standardized tests of speech and language, intelligible oral
speech in unstructured situations, an outgoing personality, and demonstrated ability to
function in the regular classroom. Preparation of teachers and classmates may be
accomplished through use of Systems O.N.E. (Orientation to Normal Environment)'.
Discussion topics of this slide-tape orientation program include: administrative
guidelines, classroom communication, hearing aids, language, reading, speech and peer
orientation. Expanded consideration of mainstream problems and practices also can be

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HUMAN COMMUNICATION, SPRING 1978

round in recent texts by Nix (1976) and Northcott (1973). Classroom acoustics should be
evaluated in regards to reverberation time, ambient noise level, and distance of the
hearing aid microphone from the teacher. Ross (1972) presents a discussion of these
concerns. Optimal listening conditions can be provided by employing auditory training
systems in the classroom. Hetherington (1975) presents a review of available systems.

As with preschool clients, a multidisciplinary approach to comprehensive (re)habilita-

tion programming is recommended for school aged hearing impaired children.
Extensive discussions of the role of educators, academic tutors, psychologists, social
workers, audiologists and speech clinicians are presented in Northcott (1973. pp. 47-96).

Whereas recommended communication skills programs for preschool hearing impaired

clients emphasize the acquisition of language and basic listening skills, formal speech
training should be stressed when these clients reach school age. Ling (1976) has
organized an auditorily based speech development program which appears appropriate
for this task. Ling regards speech as a motor skill requiring continuous practice for
optimal development. He recommends teaching sequenced speech patterns in short (two
to three minute) syllable drills practiced several times daily. During drill sessions, clients
orally produce auditorily received speech patterns. Each pattern is drilled until it can be
produced precisely, rapidly, in a variety of suprasegmental contexts, and alternated with
all other known syllables. Carryover is achieved by providing structured opportunities
for use of the overlearned speech in meaningful communication situations. (Support for
training speech as a motor skill through nonsense and meaningful speech practice can be
found in McLean's (1976) discussion of articulation development strategies.)

Ling proposes a seven stage model for speech development. During stage one,
vocalization quantities are increased through reinforcement and nonspecific vocaliza-
tion on demand is taught. Suprasegmental aspects of speech are introduced in stage two.
Using nonspecific vocalizations, clients are required to imitate speech patterns varying
in duration, intensity andj or pitch. Vowels and diphthongs are developed in stage three.
These phonemes are taught in sets with each set containing front, mid and back tongue
placements. Practice in defining the boundaries of the oral cavity is used to foster
maximum tongue movement and flexibility. Stages four through six require instruction
in simple consonants. These speech sounds are presented in sets with consonants in each
set varying in manner of production but similar in place of production. The inst ructional
order for place is sequenced from the front to the back of the mouth. Voice-voiceless
distinctions are the last simple consonant skills to be acquired in the program. During
the final stage of Ling's model, consonant blends are introduced. Sequencing in this
seventh stage is based on both the number of speech organs involved in producing each
blend and the complexity of the manner of production.

Hearing impaired clients will vary in their ability to progress through the Ling model
employing auditory cues exclusively. Children who do not advance after receiving
extensive auditory simulation can continue in the program with multisensory
instruction. Suggestions for appropriate multisensory techniques are plentiful and can
be found both in Ling (1976) and Calvert and Silverman (1975).

Clinicians are reminded to view the development of speech skills as only one component
of a comprehensive communication (re)habilitation program for school aged hearing
impaired clients. As indicated above, all areas outlined in the model of normal
communication need to be evaluated and treated, as necessary.

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 BRAINERD: COMMUNICATION (RE)HABILITA TION
Habilitation for Young Deaf Adults
As a group, congenitally deaf young adults are characterized as having normal
intellectual potential (Hoemann and UlIman, 1976) yet demonstrating low academic
achievement (Lane, 1976), delayed emotional development (Meadows, 1976) and
vocational immaturity(Lerman,1976).Comprehensive habilitation programs, therefore,
must focus on both daily living and employment skills (Bolton, 1976). Recommended
personal and social preparatory services include training in and opportunities to utilize
communication skills, basic educational skills, and independent living skills.
Recommended vocational preparatory services include evaluation of each client's work
personality and capabilities. a period of work adjustment in a simulated employment
environment. skill training, job placement and follow-up assistance as required.

Clinicians responsible for improving the communication skills of young deaf adults
should foster optimal communicative interactions between themselves and their clients.
Each client's preferred communication method is the recommended technique to be
employed for interviewing. giving directions and feedback, and counselling. Potential
alternatives include speaking, writing, fingerspelling, signing and using an interpreter.
Bornstein, et al (1976) provide strategies for the effective employment of each of the
above methods with the adult deaf popUlation.

Comprehensive communication evaluations should be completed on young deaf adult

clients regardless of their preferred method of communication. One appropraite
screening battery has been developed at the National Technical Institute for the Deaf
(NTID) (Johnson, 1976). Using CID Everyday Sentences, the NTlD communication
skills profile receptively assesses hearing (speech) discrimination, speechreading with
and without sound, manual communication, and simultaneous communication (i.e.,
reception when all of the above stimuli are employed). Reading vocabulary and
comprehension are measured with the California Achievement Test. Expressive skills of
writing intelligibility, speech intelligibility and non-verbal kinetic intelligibility (body
language) are determined with institution (NTlD) made tests. Gochnour (1973) has
outlined a variety of procedures she employs in making a more detailed evaluation of
communication skills of young deaf adults. Gochnour's article particularly should be
useful to clinicians who are inexperienced with this popUlation as she provides both
appropriate suggestions for standardized test modifications and some normative data.
Both Gochnour and Johnson remind clinicians that regardless of scores on
communication evaluations of young deaf adults employing everyday speech, they all
require training in the vocabulary of their vocational area of choice.

Communication skills development programs for young deaf adults should employ the
most expedient avenues of communication from the onset of therapy. Use of the
auditory approach as the initial method of choice is not recommended for this
popUlation. Alternative to (re)habilitation programs for younger hearing impaired
clients, formal speech reading instruction in an adult's vocational area of choice
frequently is appropriate from the onset of therapy. Factors correlated with
speechreading proficiency which can be used to structure evaluation and training
programs include the following from Jeffers and Barley (1971) and Sanders (1971):
familiarity with employed language, perceptual set to speechread, knowledge of message
topic. knowledge of visually contrasting speech movements. visual acuity, ability to
focus accurately and quickly, visual awareness and memory. peripheral vision. synthetic
ability (e.g., perceptual and conceptual closure), flexibility, and practice in reduced
levels of redundancy.

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 HUMAN COMMUNICATION, SPRING ]978

Most young deaf adults are proficient in American Sign Language (ASL) but deficient
in English language skills. Due to this first language competence in AS L. English
language remediation may be accomplished most easily through second language
instructional techniques (KannapeL 1974. among others). The English Language
Tutorial Centre at Gallaudet College employs such a bilingual philosophy (Gold berg. et
al. 1975). In order to minimize interference between the two languages. English is taught
only in the written form in the Gallaudet program.

Rehabilitation for Hearing Impaired Adults

A number of adventitiously hearing impaired adults should be referred for

communication rehabilitation services. Hardick (1976) suggests that candidates for such
programs include clients whose hearing loss makes them equivocal candidates for
amplification and clients who have previous unsatisfactory hearing aid experiences or
who hold unrealistic expectations concerning amplification.

Geriatric clients constitute the majority of adults requiring communication rehabilita-

tion. Clinicians working with this population need to be aware that hearing impairment
is not an isolated sensory deficit for the client. With the aging process, changes in the
auditory, visual, tactile, kinesthetic. olfactory and gustatory systems are all expected.
Recognition of these widespread sensory losses suggests that the value of communica-
tion rehabilitation programs for geriatric clients may be increased by integrating the
services into comprehensive sensory retraining programs. Shore (1976) outlines
intervention techniques and deprivation simulation activities for each sensory system.
Also of interest should be Oyer and Oyer's (1976) comprehensive discussions of the
communication needs and pro blems of older persons.

Communication rehabilitation programs for adventitiously hearing impaired adults can

be successful. Characteristics of such programs, according to Hardick (1976), include a
client centered philosophy, use of group therapy techniques, involvement of clients'
normal hearing friends and! or relatives, use of "graduates" in group activities. a short-
term treatment approach, consumer oriented information, and advertisement of
available services. Goals of Hardick's program include provision of information
concerning normal hearing, hearing losses, hearing aids and services offered by relevant
professionals and agencies; orientation to speechreading and the involved problems;
experimental hearing aid use; procurement of recommended hearing aid (if any);
listening improvement; and counseling regarding attitudes and behaviors. A more
extensive discussion of treatment philosophy and procedures may be found in Alpiner
( 1978).

NOTES

This definition of Total Communication has been accepted by the Conference of

Executives of American Schools for the Deaf and reported in the American Annals of
the Deaf, 1976, p. 358.

2Systems O.N. E. is available from the A. G. Bell Association for the Deaf, 3417 Volta
Place, N. W., Washington, D.e.

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 BRAINERD: COMMUNI CA nON (RE)HABILITA TION

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 BRAINERD: COMMVNICA nON (RE)HABILITA nON

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Requests for reprints should be mailed to:

Susan Brainerd
Programme in Communicative Disorders
8400 Social Science Centre
University of Western Ontario,
London, Ontario N6A 5C2

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