Child Development
Why Deaf/HH Plus matters
• Developmental disabilities in children who are Deaf/HH
are more common than you may realize
• We want children to achieve to their maximal
potential, but often the complication of hearing loss and
a developmental disability makes it hard to know how to
approach intervention
• Seeing a child meet a goal is very rewarding, even if the
child is not keeping up with peers
Hearing Loss and
Developmental Conditions
Type of Disability
Hearing Loss
GRI data
General Population
No Additional Disability
60%
86%
Cognitive (Intellectual Disability)
8.3%
0.71%
8%
0.3%
Blindness and Vision Impairment
5.6%
0.13%
ADHD
5.4%
5-10%
8%
5-10%
1.7-7%
1%
Cerebral Palsy (orthopedic)
Specific Learning Disability
Autism
From 2010 Gallaudet Research Institute
Boyle, et al Pediatrics 2011
Risks and Etiologies
• Etiology can confer risk and does not protect from
other risk factors for developmental problems
– Risk factors for hearing loss often overlap with risk
factors for developmental delay
– Risk factors for developmental delay can co-occur in
children with hearing loss unrelated to the cause of
hearing loss
Risk factors for developmental delays
• Neonatal history (low birthweight, prematurity,
asphyxia, bleeding into the brain)
• Congenital infections (CMV)
• Meningitis
• Environmental exposures (Lead)
• Failure to thrive
• Iron Deficiency Anemia
• Maternal Substance Abuse
• Environmental deprivation
• Family history of learning difficulties, attention
problems
Risk factors for developmental delay
in Deaf/HH
• Neonatal factors
– prematurity
– intraventricular hemorrhage
– necrotizing enterocolitis (NEC)
– prolonged ventilation
•
•
•
•
Symptomatic congenital CMV
Bacterial meningitis
Some syndromes
Family history of learning difficulties, attention problems
Etiology may or may not be related to
disabilities and is not protective
• Some reports of children with GJB2 (connexin)
mutations as cause of hearing loss have improved
post-cochlear implant outcomes1
• Other data suggest no differences2
• However, children with GJB2 mutations are not
protected from other developmental problems3,4
1. Cullen et al Laryngoscope 2005:114:1415-1419; 2. Dahl et al Audiology Neurotology
2003:8:263-268; 3. Wiley et al 2006 IJPO 70:493-500; 4. Kenna et al. Am J of Genetics
2007: 143A: 1560-6.
Child Development
• Many theories of child development,
none of which explains everything!
– Neurologic maturation
– Behavioral/environmental
– Relationships with others
– Developmental tasks and how a child
accomplishes them
– Child temperament/fit to environment
Approach to developmental disabilities
•
•
•
•
Identify strengths and weaknesses.
Build upon and use strengths
Remediate weaknesses
Find strategies around weaknesses to allow success (modifications,
alternative strategies)
• Identify goals (short-term, long-term)
• Functional goals (so, that…)
Mel Levine All Kinds of Minds, www.allkindsofminds.com
5 Possible Developmental Trajectories
70
60
Score
50
40
30
20
10
0
1
6
11
16
21
26
31
36
41
46
51
56
Age in Months
Maintained functioning comparable to age peers
Achieved functioning comparable to age peers
Moved nearer functioning comparable to age peers
Made progress; no change in trajectory
Did not make progress
-- Hebbeler, 2006
Factors Influencing Developmental
Outcomes:
• Age of Identification
• Carry over of activities into the
home environment
• Audibility of the Speech
Spectrum
• Benefit from and consistency of
use of amplification
• Quality of language exposure &
educational services
• Presence of additional
disabilities (30-40%)
• Deaf (10%) vs. hearing
parents (90%)
• Proficiency of caregivers
communication in chosen
mode
• The natural grieving process
of family and impact on
social/emotional development
• View of deafness as disability
or culture
The Gap
Children who are Deaf/HH Plus often are
under-achieving as compared to their
cognitive potential
Accounting for Development
• One of the most difficult aspects of studying outcomes
among children with disabilities is the choice of an
appropriate comparison (control) group
• When language is the goal, the language skill set in
children should be similar to their developmental level
(diagnosis alone may not always provide clarity on
outcomes)
Specific Disability Label: Not Very Predictive
5.5
a. scatter plot of nonverbal cognition and language
5.0
4.5
4.5
Log Receptive Quotient
Log Receptive Quotient
5.0
b. scatter plot of disability diagnosis and language
4.0
3.5
3.0
2.5
2.0
4.0
3.5
3.0
2.5
2.0
R2 = 0.68
1.5
R2 = 0.07
1.5
20
30
40
50
60
70
80
90
Nonverbal cognitive quotient
100
110
120
CP
CHARGE
GLOBAL
Disability Diagnosis
OTHER
In General
• Nonverbal cognitive abilities biggest predictor of
language skill progress (necessary but not sufficient)
• In children who are DHH Plus, language skills
significantly lower than age-cognitively matched
peers
• Language levels not commensurate with
nonverbal cognitive abilities
Laryngoscope 2010 (120) 405-413; Research in Developmental
Disabilities 2011 (32) 757-767
Labels: label or handle?
• Sometimes labels open doors
– Follow the funding streams
• Sometimes labels close doors
– A label may keep a child out of an appropriate program,
but the label itself says very little about the child
• Disability labels do not tend to provide an effective
guide to our understanding of a child’s capacities
Perspective Example: ADHD
• Hyperactive
• Intrusive
• Loud
• Energetic
• Joyous
• Vibrant
Labels
• Activity:
– How many labels could be attributed to you?
– What don’t those labels take into account?
• Think of a child who is Deaf/HH plus on your caseload
– How many labels does that child have?
– What don’t those labels take into account?
Perspective activity
• 3 per group
• Do not share your paper with others in your group
• Without talking or signing, try to indicate to the others in
your group what is on your paper
• Once everyone has tried to indicate what is on the paper,
you may then share your paper with others.
Perspective activity
• The next step of the activity is to try to work together to determine
what the three papers when put together represent.
• Debriefing Questions:
• How difficult was it to try to share what was on your paper was with
others?
• What did you learn in trying to determine the overall final product?
IDEA and labels:
When it takes a village
• But what about IDEA and picking a primary category
for Part B services when you really need more than
the primary label?
“I would have liked to have some information to give
the school about the adjustments to be made in the
classroom. I wish I had more concrete things to tell the
school.”
• Sometimes children’s services (IEP) are guided by
labels rather than priorities
Educational IEP data
• IEP data from school district on all children
classified as having a hearing loss
• Data allowed for longitudinal look at services and
educational category (primary label)
Borders C et al Students who are Deaf with Additional Disabilities: Does Educational Label Impact
Language Services? Deafness & Education International. 2015: 17(4): 204-218
Primary Educational Label
across time
65%
63%
60%
55%
What “label” is missing?
HI- Hearing Impaired
SL: Speech/Language Delay
CD: Cognitive Disability
Multidis: Multiple Disability
SLD: Specific Learning Disability
OHI: Other Health Impaired
PDSD: Preschool Disabilities
ED: Emotional Disturbance
52%
Number of children
50%
45%
40%
35%
30%
25%
20%
20%
15%
11%
9%
10%
7%
7%
7%
7% 7%
4%
5%
4%
2%
2%
0%
0%
HI-03
S/L Delay 05
CD - 09
MULTIDIS-01
SLD - 10
OHI-15
PSDS-11
0%
ED-08
Is disability label associated with types
and amounts of services received?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
SLD - 10
Audiologic
SLP
CD - 09
INTERPRETER
MULTIDIS-01
INT SPEC
HI-03
SST HI
PT
OHI-15
OT
S/L Delay - 05
SPEC ED CLASSROOM
Borders C et al Students who are Deaf with Additional Disabilities: Does Educational Label Impact
Language Services? Deafness & Education International. 2015: 17(4): 204-218
Labels probably do matter
• Of course, how you advocate for appropriate goals and
implementation of services is most important
• Discussion: Implications for practice:
– IFSP to IEP hand-off process
Developmental Domains
•
•
•
•
•
•
•
•
Gross Motor
Fine Motor
Vision
Problem Solving
Personal/Social
Language
Sensory Integration
Behavior
Gross Motor
• Common misconception:
– Children who are deaf walk later because they can’t hear.
• Children generally walk between 9-15 months of age.
• Family patterns are common (all children walking at 14-15
months of age).
Gross Motor Skill Development
SKILL
Median age
Sits alone
6 months
Rolls from prone
6.4 months
Stands alone
11 months
Walks alone
11.7 months
Walks up stairs (rail)16.1 months
Range
5-8
4-10
9-16
9-17
12-23
Gross Motor Development
• Children tends to develop from head to toe
– Head and trunk control develop first
– Then movements of arms and legs
• Gross motor development also progresses from inside to
outside
– Can kick legs up and down, then crawling, then walking.
Gross Motor
• 93% of Deaf/HH children without vestibular abnormalities have
normal or above average motor development*
• Deaf/HOH children walking later than 15 months warrant an
evaluation of why they are delayed.
• If children have significant vestibular abnormalities (cochlear
malformations: mondini deformities, cochlear hypoplasia), this can
impact balance for walking.
*Lieberman et al American Annals of the Deaf 2005 149:281-289
Gross Motor
• If children have significant vision issues,
or Usher Type I, age of walking can be
delayed.
• Children with CHARGE Syndrome
almost uniformly walk late and should
receive PT early on (vision and balance
and tone affected).
Gross Motor Problems
• Low muscle tone (hypotonia)
– Have to develop strength to overcome low tone
– Sometimes less awareness of where you are in space
• High muscle tone (spasticity, cerebral palsy)
– Can make it hard to move easily, might have troubles bending to sit or
walking if legs are tight and cross over, might tiptoe walk.
• Balance
– Might affect walking balance, riding a bike, ice skating
– Some children are in constant motion to counter the difficulties with
balance (bicycle stays upright when moving, not when it’s still)
Motor Patterns in Cerebral Palsy
• Children with cerebral palsy tend to have atypical motor
patterns, not just delayed milestones.
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–
–
–
–
–
Acquire handedness before a year of age
Cross midline to pick up a toy
Persistent fisting after 4 months of age
Log roll rather than segmental roll
Leg scissoring when picked up
Persistent primitive reflexes
Case
• 2 ½ year old girl with significant cerebral palsy and profound
SNHL from Group B Strep Meningitis related to an immune
dysfunction.
• Very medically complicated (multiple infections, receives TPN
for growth, kidney problems, MRI of the brain showed
encephalomalacia.
• At one point was able to commando crawl, but now can’t.
Can bear weight in standing.
• Family uses sign language with her. Mother estimated her
understanding of 100 signs.
Case
• She loves books.
• She uses preferential eye gaze and some sign
approximations. She could make some choices and used
different vocalizations to indicate different states.
• An augmentative communication evaluation at this time
primarily focused on building pre-communication skills.
Case
• Once implanted, her mother was very proactive when she got the
implant to carry her to all new sounds in the environment.
• At 4 ½ years (1 ½ years post implant), she understands some
simple commands and responds to behavior management strategies
for whining. She can nod yes.
• They continue to sign and speak to her (deaf mentor works with
them to continue to help them learn signs).
• She is potty trained. They are working on walking with a pacer gait
trainer.
Points
• Proactive family
• Cognitive skills difficult to assess (eye gaze)
• Augmentative communication evaluation
• Positioning
• Use of interpreter
Fine Motor
• Fine motor development can mirror language development, however
there are no good physiologic reasons why fine motor skills should be
delayed in children who are deaf/hoh.
• Available studies on children with cochlear implants noted gross motor
skills at chronological age, but fine motor skills more consistent with
language age equivalents.
Horn et al Laryngoscope 2006 2006:116:1500-1506
Triological Society Abstract 708
www.triological.com/admin2/views.cfm?is=708
Fine Motor Skill Development
SKILL
Median age
Object transfer
Neat pincer grasp
Holds crayon well
5.5 months
8.9 months
11.2 months
Range
4-8
7-12
8-15
Fine Motor: Grasp Patterns
4 mths:
5 mths:
7 mths:
7-8 mths:
9-10 mths:
By 2 years:
finger & palm
thumb active
raking grasp
inferior pincer
refined pincer
holds item in hand with wrist supination
Fine Motor Skills
• As a strength
– figure out how things put together, take apart
– can easily take off hearing aid, implant
– signs may be clearer, more refined
• As a weakness
– may require adaptations to pick up objects, play with toys (switch toys,
weighted spoon)
– may have a harder time taking off hearing aid!
– can affect clarity of signs
Fine Motor Activities
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•
•
•
•
•
Strengthen hands with playdoh
Drawing (markers, jumbo chalk, crayons)
Finger painting
Finger puppets
Threading beads, (can use big buttons and yarn) lacing cards
Pipe cleaners
• A GOOD OT IS KEY!
• Curriculum: Handwriting Without Tears
Fine Motor Skills and Signing
• Movement of a sign is easier to imitate than the more refined hand
shape.
• The child must also be able to reverse the hand shape, movement,
location in his/her mind to recreate the sign correctly.
• Movement toward the body is easier to make than movements away
from the body.
– (want, eat, love vs. thank you, stay, bad)
Pre-Sign Language Motor Skills by Marsha
Dunn Klein (1988 Communication Skill Builders)
Fine Motor Skills and Signing
• Signs with the palm towards the face are easier than holding the palm away
from the face (sour, candy, pretty vs. horse, duck)
• Movement toward the midline is easier than movement away from midline.
(shoe, more, stop vs. ready, different)
• Easier if do not have to cross midline (some children have particular difficulty
with crossing midline or co-ordinating both hands together in skills)
Fine Motor Skills and Signing
• Movement is easier with touch than without touch
(proprioceptive input).
• Performing a movement in the air provides less feedback
than performing a movement that is reinforced by touching
the body. (chair, on, friend vs. airplane, milk, hot)
• Sign language learning can use multi-sensory training
techniques.
Fine Motor Skills and Signing
• Signs are easier if within a child’s visual field (milk, slow,
stand, book vs. cow, rooster, horse, stuck)
• Pronated forearm signs are easier than neutral signs and
easier than supinated signs. (child vs. with vs. give)
Fine Motor Skills and Signing
• The easiest signs to imitate are those that:
– have a movement toward the body
– performed at or toward but not across the midline
– are performed with touch
– performed with vision
– performed with a pronated or supinated forearm
Fine Motor Skills and Signing
• Unilateral signs are easier than signs
requiring both hands to work in concert.
• Bilateral signs (both hands doing the same
movement and hand shape) are the next
easiest to imitate and learn.
Fine Motor Skills and Signing
• Lead-assist signs are the next difficult to learn (dominant
hand performs movement, non-dominant hand stays in
one position)
– slow, clean
• Reciprocal signs are the most difficult (hands do opposite
movements…beating a drum, unscrewing a jar)
– exciting, walk, maybe
Fine Motor Skills and Signing
• Hand Shapes
• Whole hand signs are easiest to imitate (S, A, elongated O, 5
hand shapes)
• A: yes, sorry, love, bicycle
• Elongated O: food, more, money, teach
Fine Motor Skills and Signing
• Thumb-Isolation Signs come next (B, C, 10)
• Index-Finger Isolation Signs (thirsty, pain)
– Children with considerable hypotonia may have difficulty with
this…middle finger to point, more stability provided by neighboring
fingers.
• Thumb-Index Isolations (turkey, green)
Fine Motor Skills and Signing
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•
•
•
•
•
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Little finger isolation
Index and middle finger (2)
Thumb and index and little (ILY)
Thumb and index and middle (3)
Thumb and little (Y)
Middle finger
Complex finger isolations (require isolation of ring finger or several fingers in
different positions (K, airplane, 7, ILY)
Fine Motor Skills and Signing
• Complex signs
– Each hand is performing a different shape
– Signs that require more than one movement
– Signs that require a sequence of movements
Analyzing Signs
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•
•
•
•
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Movement in relationship to the body
Hand usage pattern
Hand shape of the lead hand
Hand shape of the assister hand
Is it a complex sign?
Does the sign-learner have the motoric skill to produce
this sign?
Pre-Sign Motor Assessment
• Informal Assessment
– Spontaneous behaviors with hands
• Hands held together, apart, still, moving, movements repetitive or
patterned, hands tapped, shaken
– Lead hand
• Prefer to use one hand or both, hand dominance
– Repertoire behaviors
• When manipulating objects, doing functional tasks, what movements are
seen in relationship to the body, what hand useage patterns and hand
shapes are present
– Imitative behaviors
• Which repertoire behaviors can a child imitate
Pre-Sign Motor Assessment
• Formal Assessment
• Use objects, activities to evaluate
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•
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Movements in relationship to the body
Hand useage patterns
Basic hand shapes
Intermediate hand shapes
Complex motor patterns
• Summarize preferred movements, hand useage, hand shape
patterns
• Develop next-step hand useage, hand shape patterns or sign
adaptations if physically unable
• Motivating concepts to sign are also important considerations.
Functions of Behavior
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•
•
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Escape (I get to avoid something I don’t like)
Tangible (I get what I want)
Attention (I get your attention)
Automatic (Because it feels good)
Why Vision Matters: Visually Related
Developmental Milestones
Infant
2 months
Alert with widening of eyes to
visual stimulus or face 8-12
inches
Momentary eye contact with
adult
Horizontal tracking across
midline
Follows moving person 6 ft.
away
Prolonged eye contact with
an adult
Smiles in response to a
smiling face
Raises head 30 degrees
from prone position
1 month
Follows visual stimulus in
horizontal arc 60 degrees on
either side of midline
Follows visual stimulus vertically
30 degrees above and below
horizontal midline
3 months
Eyes and hand follow smoothly
through 180 degree arc
Regards own hand
Looks at objects placed in hand,
begins visual and motor
coordination
4-5 months
Spontaneous social smile in
response to familiar adult
Reaches on sight to a 1 inch
cube presented 12 inches away
Notices raisin presented 12
inches away
5-6 months
Smiles at mirror image
7-8 months
Picks up raisin by raking
Sits up
8-9 months
Visual attention to details of object,
such as facial features of dolls
Pokes at holes in pegboard
9 months
Neat pincer grasp
Crawling
12-14 months
Perceives motor tasks, for example,
stacks blocks and places pegs in round
hole
Stands and walks
Why is it Important?
• Vision provides motivation to move (motor development) and
develop
• Vision is critical in language development
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–
–
–
Seeing sign language
Lip-reading
Reading facial expressions, non-verbal communication
Development of Literacy
How do we identify deaf-blindness
•
•
•
•
Understanding risk factors and monitoring
Recognizing concerning visual behaviors and eye findings
On-going monitoring (without risk factors)
Importance of a functional vision assessment