About the Book

The fourth edition of Children With Hearing Loss: Developing Listening and Talking, Birth to Six is a dynamic compilation of important information for the facilitation of spoken language for infants and young children with hearing loss. This text covers current and up-to-date information about auditory brain development, listening scenarios, auditory technologies, spoken language development, and intervention for young children with hearing loss whose parents have chosen to have them learn to listen and talk.

The book is divided into two parts. Part I, Audiological and Technological Foundations of Auditory Brain Development, consists of the first five chapters that lay the foundation for brain-based listening and talking. These chapters include neurological development and discussions of ear anatomy and physiology, pathologies that cause hearing loss, audiologic testing of infants and children, and the latest in amplification technologies. Part II, Developmental, Family-Focused Instruction for Listening and Spoken Language Enrichment, includes the second five chapters on intervention: listening, talking, and communicating through the utilization of a developmental and preventative model that focuses on enriching the child’s auditory brain centers.

New to the Fourth Edition:

  • All technology information has been updated as has information about neurophysiology.
  • The reference list is exhaustive with the addition of the newest studies while maintaining seminal works about neurophysiology, technology, and listening and spoken language development.
  • New artwork throughout the book illustrates key concepts of family-focused listening and spoken language intervention.
  • A PluralPlus companion website with PowerPoint lecture slides, study questions, a list of related resources and links, and the following documents that can be downloaded or printed:
    A Framework for Maximizing Caregiver Effectiveness in Promoting Auditory/Linguistic Development in Children with Hearing Loss (from Chapter 10) and Targets for Auditory/Verbal Learning (Appendix 3)

This text is intended for undergraduate and graduate-level training programs for professionals who work with children who have hearing loss and their families. This fourth edition is also directly relevant for parents, listening and spoken language specialists (LSLS Cert. AVT and LSLS Cert. AVEd), speech-language pathologists, audiologists, early childhood instructors, and teachers. In addition, much of the information in Chapters 1 through 5, and also Chapter 7 can be helpful to individuals of all ages who experience hearing loss, especially to newly diagnosed adults, as a practical “owner’s manual.”

About the Authors

Elizabeth B. Cole, EdD, CCC-A, LSLS Cert. AVT, is the former Director of CREC Soundbridge in Connecticut and a former professor at McGill University in Montreal, and is now enjoying a very active semi-retirement.

Carol Flexer, PhD, CCC-A, LSLS Cert. AVT, received her doctorate in audiology from Kent State University in 1982. She was at The University of Akron for 25 years as a Distinguished Professor of Audiology. Dr. Flexer lectures and consults extensively nationally and internationally about pediatric audiology issues.

Table Of Contents

Part I. Audiological and Technological Foundations of Auditory Brain Development

Chapter 1. Neurological Foundations of Listening and Talking: We Hear With the Brain


Begin Conversations with the Critical Question: What Is the Family’s Desired Outcome?

Typical Infants: Listening and Language Development

Auditory Neural Development

New Context for the Word Deaf

Hearing Versus Listening

A Model of Hearing Loss: The Invisible Acoustic Filter Effect

Putting It All Together in a Counseling Narrative: Think About Hearing Loss as a Doorway Problem


Next Steps: What Will It Take to Optimize the Probability of Attaining a Listening and Spoken Language Outcome

Chapter 2. The Audiovestibular System

The Nature of Sound

Subconscious Function

Signal Warning Function

Spoken Communication Function


Audibility Versus Intelligibility of Speech

The Ling 6-7 Sound Test: Acoustic Basis and Description

Audiovestibular Structures

Data Input Analogy

Outer and Middle Ear

Inner Ear to the Brain

The Vestibular System: The Sensory Organs of Balance

Chapter 3. Hearing and Hearing Loss in Infants and Children



Degree (Severity): Minimal to Profound

Timing: Congenital or Acquired

General Causes: Endogenous, Exogenous, or Multifactorial

Genetics, Syndromes, and Dysplasias

Connexin 26

Genetic Testing


Inner Ear Dysplasias

Medical Aspects of Hearing Loss

Conductive Pathologies and Hearing Loss

Sensorineural Pathologies and Hearing Loss

Mixed, Progressive, Functional, and Central Hearing Losses

Synergistic and Multifactorial Effects

Auditory Neuropathy Spectrum Disorder (ANSD)

Vestibular Issues


Chapter 4. Diagnosing Hearing Loss


Newborn Hearing Screening and EHDI Programs

Test Equipment and Test Environment

Audiologic Diagnostic Assessment of Infants and Children

Test Protocols

Pediatric Behavioral Tests: BOA, VRA, CPA, Speech Perception Testing

Electrophysiologic Tests: OAE, ABR/ASSR, and Immittance

The Audiogram

Configuration (Pattern) of Thresholds on the Audiogram

Formulating a Differential Diagnosis

Sensory Deprivation

Ambiguity of Hearing Loss

Measuring Distance Hearing


Chapter 5. Hearing Aids, Cochlear Implants, and Remote Microphone (RM) Systems


For Intervention, First Things First: Optimize Detection of the Complete Acoustic Spectrum

Listening and Learning Environments

Distance Hearing/Incidental Learning and S/N Ratio

ANSI/ASA S12.60-2010: Acoustical Guidelines for Classroom Noise and Reverberation

Talker and Listener Physical Positioning

Amplification for Infants and Children

Hearing Aids

Bone Anchored Implants for Children (Also Called Osseointegrated [Osseo] Implants) or Bone Conduction Hearing Devices

Wireless Connectivity

HATs for Infants and Children: Personal-Worn RM and Sound-Field FM and IR (Classroom Amplification) Systems

Cochlear Implants

Auditory Brainstem Implant (ABI)

Measuring Efficacy of Fitting and Use of Technology

Equipment Efficacy for the School System


Part II. Developmental, Family-Focused Instruction for Listening and Spoken Language Enrichment

Chapter 6. Intervention Issues

Basic Premises

Differentiating Dimensions Among Intervention Programs

Challenges to the Process of Learning Spoken Language

Late to Full-Time Wearing of Appropriate Amplification or Cochlear Implant(s)

Disabilities in Addition to the Child’s Hearing Loss

Ongoing, Persistent Noise in the Child’s Learning Environment

Multilingual Environment

Educational Options for Children with Hearing Loss, Ages 3 to 6

Chapter 7. Auditory “Work”


The Primacy of Audition

The Acoustics-Speech Connection




The Effect of Hearing Loss on the Reception of Speech

A Historical Look at the Use of Residual Hearing

The Concept of Listening Age

Auditory Skills and Auditory Processing Models

Theory of Mind and Executive Functions

How to Help a Child Learn to Listen in Ordinary, Everyday Ways

Two Examples of Auditory Teaching and Learning

Scene I: Tony

Scene II: Tamara

Targets for Auditory/Linguistic Learning

A Last Word

Chapter 8. Spoken Language Learning


What’s Involved in Talking?

Intentionality/Speech Acts

Presuppositional Knowledge

Discourse/Conversational Conventions

Other Essential Rule Systems in English

How Does a Child Learn to Talk?

Relevance for Intervention Decisions

How Should Intervention Be Organized?

Chapter 9. Constructing Meaningful Communication


The Affective Relationship

The Child’s Development of Interactional Abilities

Joint Reference, or Joint Attention

Turn-Taking Conventions

Signaling of Intention

Characteristics of Caregiver Talk

1. Content: What Gets Talked About?

2. Prosody: What Does Motherese Sound Like?

3. Semantics and Syntax: What About Complexity?

4. Repetition: Say It or Play It Again

5. Negotiation of Meaning: Huh?

6. Participation-Elicitors: Let’s (Keep) Talk(ing)

7. Responsiveness

Issues About Motherese

How Long Is Motherese Used?

Motherese: Why Do We Use It?

Motherese: Is It Immaterial or Facilitative?

Chapter 10. Interacting in Ways That Promote Listening and Talking


The Emotional Impact of a Child’s Hearing Loss on the Family

Adult Learning

What Parents Need to Learn

Role of the LSL Practitioner

Components of Intervention for Babies and Young Children with Hearing Loss

When to Talk with Your Child and What to Talk About

A Framework for Maximizing Caregiver Effectiveness in Promoting Auditory/Linguistic Development in Children with Hearing Loss

Background and Rationale

Structure of the Framework

Getting a Representative Sample of Interacting

Discussing the Framework with Parents

Ways of Addressing Parent-Chosen Interactional Targets

Determining and Sequencing Targets Specific to the Child’s Development of Auditory, Language, and Speech Development

Relationship Between Family and LSL Practitioner

Teaching Through Incidental and Embellished Interacting

Teaching Through Incidental Interacting

Embellishing an Incidental Interaction

Teaching Spoken Language Through Embellished Interacting

Teaching Listening (Audition) Through Embellished Interacting

Teaching Speech Through Embellished Interacting

Preplanned Parent Guidance Sessions or Auditory-Verbal Therapy/Instructional Sessions

Where Should the Auditory-Verbal Therapy (LSL)/Instructional Sessions Occur?

What Happens in an Auditory-Verbal Therapy/Instructional Session to Address Child Targets?

Components to Be Accomplished in a Typical Preplanned Session to Address Child Targets

Sample Preplanned Scenario


About the Benefits and Limitations of Preplanned Teaching

What Does the Research Say?

Appendix 1: How to Grow Your Baby’s or Child’s Brain Through Daily Routines

Appendix 2: Application and Instructions for the Ling 6-7 Sound Test for Distance Hearing

Appendix 3: Targets for Auditory/Verbal Learning

Appendix 4: Explanation for Items on the Framework

Appendix 5: Checklist for Evaluating Preschool Group Settings for Children With Hearing Loss Who Are Learning Spoken Language

Appendix 6: Selected Resources

Appendix 7: Description and Practice of Listening and Spoken Language Specialists: LSLS Cert. AVT and LSLS Cert. AVEd

Appendix 8: Principles of Certified LSL Specialists

Appendix 9: Knowledge and Competencies Needed by Listening and Spoken Language Specialists (LSLS)

Appendix 10: Listening and Spoken Language Domains Addressed in This Book


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