1. M.A.THESIS IN LINGUISTICS
FIRST LANGUAGE ACQUISITION IN
HEARING IMPAIRED CHILDREN
WITH COCHLEAR IMPLANT
L.C.SENEVIRATNE
Department of Linguistics
University of Kelaniya
2011
FGS/MA/LING/09/116

2. Contact;
Chula Seneviratne
seneviratne29@hotmail.com

3. DECLARATION
Declaration by the candidate.
I hereby declare that the work embodied in the thesis was carried out by me in the
Department of Linguistics. It contains no material previously published or written by
another person. It has not been submitted for any degree in this university or any
other institution.
Name: L.C.Seneviratne.
Signature :................................... Date: 31st January 2012
(Candidate)
Certification of the above statements by the supervisor.
I hereby certify that I have supervised this dissertation.
Name: Professor G.J.S. Wijesekara.
Signature:.............................................. Date: 31st January 2012
(Supervisor)
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4. ABSTRACT
This thesis talks about the language acquisition of hearing impaired children
with cochlear implant. Once they receive the CI only, these children gain the ability
to perceive language and then only they will be led to produce words after different
stages of L1 (first language) acquisition process. This is mainly because until then
they are not being exposed to auditory input. Therefore, this thesis basically deals
with the contributory factors towards making L1 acquisition successful within CI
(cochlear implanted) children. These contributory factors are age at implant, parental
support and the degree of rehabilitation. Consequently, it was also investigated how
these CI children acquire their first language (Sinhala language) and the
developmental stages in accordance with English language acquisition process. This
once again pays attention to find out the significances of language components with
related to Sinhala language in their production. Nevertheless, this thesis stresses on
the appropriate language rehabilitation methods which would suit different ages
basically, the cochlear age (implant age) which means after CI children receive
auditory input.
Various methods were used in collecting data in order to prove the topic of
this thesis. Therefore, focus group discussions, telephone conversations,
questionnaires, direct observation, interviews were used in the process of collecting
data. Overall, it was quite evident that one could easily reach the final conclusions of
this thesis without any doubt due to the accurateness of these data collecting
methods. Still there could be differences in the levels and ways of L1 acquisition of
CI children since this is not unique to all.
Therefore, it was identified that all the above factors contribute a lot towards
making these CI children learn their mother tongue in every aspect of language such
as phonologically, morphologically, syntactically etc. Nevertheless, it is expected to
eradicate the misconception that, a HI child could easily acquire L1 merely with a
CI, because ultimately it was proven that all the above mentioned factors are equally
important towards making L1 acquisition effective.
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5. ACKNOWLEDGEMENTS
I make this opportunity to thank all those who helped me in numerous ways
to make this thesis a great success and it’s a pleasure to thank all of them.
Initially, I will forever be indebted to two fabulous people for their direct and
constant support provided throughout this thesis. Without them I’m sure I would
never have been able to do this. They are my supervisor and my husband.
My supervisor Professor G.J.S. Wijesekara played many roles being a
mentor, encourager, comforter and supporter at several instances. Whenever I was
in need of her help she always came up with a smile to help me irrespective of all her
other busy schedules. Your gentle encouragement and proposals of creative options
took me a long way in the course of this study. Nevertheless, I am really grateful to
you for giving guidance through your encyclopedic practice of linguistics which
really inspired me.
Next, I want to thank my dearest husband Jagath Seneviratne sincerely and
warmly, who rendered continuous support at every level. Your encouragement,
affirmation and advice were immediately responsible for this achievement. Your
endless faith in me and commitment to raise me up through what you knew I could
do (even when I didn’t) is the direct catalyst for me. Everyone dreams to have a
husband like you but I’m very lucky to have you.
In the same way, I would like to give a big thank you to my two darling
daughters Dinuki and Malki for their forbearance in my absence whenever I was
busy with this research.
Furthermore, there are so many other people who helped me in collecting
data and they all receive my heartiest gratitude. Among them Dr. A.D.K.S.N.
Yasawardana , E.N.T. surgeon and Mrs. Thamara Perera, nursing officer are paid
due respect and gratitude at this moment for supplying me with data.
The immense knowledge of cochlear implant which I gained from
Wickramarachchi Institute of Speech and Hearing was mainly due to the helping
hand of its proprietor Mr. M. Wickramarachchi and to the professional collaboration
of the rest of the staff. Among them Mrs. Preethi Peiris, my beloved friend, you
have become one of the strongest pillars behind this research, as you did not have a
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6. second thought at any time in helping me. Thank you so much for being
characteristically generous.
Moreover, my heartfelt gratitude goes to Mrs. Hema Fernando, a teacher, a
speech therapist for giving me every possible opportunity to investigate the L1
acquisition in CI children who came to her for rehabilitation programmes.
Dear parents, you have been so supportive to me by revealing all the
necessary facts which helped a lot in doing this research. Thank you so much for
your immense support.
Last but not least, I would thank my dear CI children who have been with me
for several months giving me the fullest support to make this task a success. If not for
you all my dear children I will never have this prestigious opportunity.
Once again, I owe my deepest gratitude to all the above individuals and all
the other people whose names are not mentioned but have assisted me one way or
another.
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7. CONTENT
DECLARATION...........................................................................................................i
ABSTRACT.................................................................................................................ii
ACKNOWLEDGEMENTS.........................................................................................iii
List of Tables.............................................................................................................viii
List of Figures..............................................................................................................ix
List of Abbreviations....................................................................................................x
CHAPTER ONE...........................................................................................................1
1.0 Introduction.........................................................................................................1
1.1 Classification of Hearing Impairment ................................................................1
1.1.1 Measuring Hearing Loss..............................................................................2
1.1.2 The Aim of this Thesis.................................................................................3
1.1.3 History of Hearing Aids...............................................................................4
1.1.4 History of Cochlear......................................................................................4
1.2 Objectives...........................................................................................................5
1.2.1 Parental Support.........................................................................................5
1.2.2 Age at implant..............................................................................................6
1.2.3 Language Development...............................................................................7
1 .2.4 Rehabilitation Process and Strategies.........................................................7
1.3 Research Problem...............................................................................................8
1.4 Research Hypothesis ..........................................................................................9
1.5 Research Methodology.......................................................................................9
1.6 Significance of the Research.............................................................................10
CHAPTER TWO.......................................................................................................12
2.0 Introduction.......................................................................................................12
2.1. Way we hear....................................................................................................12
2.1.1 The sections of the ear...............................................................................12
2.2. Hearing Impairment.....................................................................................14
2.3. Cochlear Implant..............................................................................................18
2.3.1 What is a Cochlear Implant and how it works...........................................18
2.4. The CI surgery.................................................................................................22
2.4.1. Pre operative evaluation of a CI................................................................22
2.5. Factors which influence the efficacy of L1 acquisition in CI children............24
2.6. Conclusion.......................................................................................................26
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8. CHAPTER THREE....................................................................................................27
3.0. Introduction......................................................................................................27
3.1. Parental Support...............................................................................................27
3.1.1. Responsibilities of these parents at different levels..................................29
3.1.2. Parental Support Towards L1 Acquisition................................................32
3.3 –Rehabilitation Process.....................................................................................38
3.3.1. Developing listening skills in CI children................................................39
3.3.2. Developing Speaking Skills......................................................................49
3.3.3. Some Activities used in Rehabilitation Programmes....................................51
3.3.4..Mainstream Education..................................................................................57
3.4. Conclusion.......................................................................................................58
CHAPTER FOUR.......................................................................................................60
LANGUAGE DEVELOPMENT IN CI CHILDREN................................................60
4.0 Introduction ......................................................................................................60
4.1 Introduction to Language Development.......................................................60
4.1.1- Language Development and Age at Implant............................................62
4.3. Language Development and Rehabilitation.................................................81
4.4. Language Development and Parental Support.............................................83
4.5. Social – Emotional Development of a CI child ..............................................83
4.6. Analysis of Language Acquisition in CI children. ........................................85
4.6.1. Auditory – Verbal Analysis......................................................................86
4.6.2.2.1. Phonological Development................................................................97
4.6.2.2.2.- Lexical Development.........................................................................99
4.6.2.2.3. Morphological Development...........................................................103
4.6.2.2.4. Syntactic Development.....................................................................105
4.7. Conclusion.....................................................................................................106
CHAPTER 5.............................................................................................................108
GENERAL CONCLUSION.....................................................................................108
5.0- Introduction...................................................................................................108
5.1. About Cochlear Implant.................................................................................108
5.2. Summary of Main Findings ..........................................................................109
5.2.1. Age Factor...............................................................................................109
5.2.2. Parental Support......................................................................................112
5.2.3. Rehabilitation Process.............................................................................112
5.2.4. Language Development..........................................................................113
5.3 Future Research Problems..............................................................................116
APPENDIX 1............................................................................................................118
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9. APPENDIX 2............................................................................................................119
APPENDIX 3............................................................................................................125
BIBLIOGRAPHY.....................................................................................................126
vii

10. List of Tables
Table 2.1 - Hearing Process 14
Table 3.1 - Cochelear Implant Listening Skills Development 41
Table 3.2 - Check Table 48
Table 4.1 - Sounds of Speech 63
Table 4.2 - Stages of Language Development In Children 64
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11. List of Figures
Figure 2.1 - Levels of hearing loss 15
Figure 2.2 - OAE Report 23
Figure 3.1 - Model of the aided audiogram 40
Figure 3.2 - Ling-6 Sounds and their frequency levels 47
Figure 4.1 - Audiograms 61
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12. List of Abbreviations
CI - Cochlear implant
CI children - Cochlear implanted children
HI - Hearing impaired
L1 - First language (Throughout this thesis L1 of these CI children is
considered as Sinhala language)
x

13. CHAPTER ONE
GENERAL INTRODUCTION
1.0 Introduction
This chapter will basically give a brief introduction about this whole research
which is based on language acquisition in hearing impaired children with cochlear
implant (CI). Furthermore, this will also discuss about age at implant, parental
support and rehabilitation as the main factors which contribute towards the efficacy
of a CI.
1.1 Classification of Hearing Impairment
Hearing impairment is a disability which could be diagnosed at several
instances. It could be identified prelingually as well as post lingually. Pre lingual
hearing impairment means a child becoming deprived of auditory input before
acquiring the language and post lingual hearing impairment means a person or a
child becoming deprived of auditory input after acquiring the language. When we
talk about the pre lingual hearing impairment it could be once again classified in
different ways. One instance of becoming pre lingually hearing impaired is basically
due to heredity. Apart from that, other external factors like disorders within the
child’s auditory system could cause this impairment or it could be either due to
complications during the pregnancy period. Anyway the symptoms for this kind of
pre lingual deafness would be the same in an infant irrespective of the cause of
getting pre lingually hearing impaired.
Post lingual hearing impairment occurs basically due to some illness after a
child acquiring his or her mother tongue. Although here we stress on children, it does
not mean that the adults are safe enough to be away from becoming hearing impaired
due to several illnesses. Meningitis is a very famous ailment which causes this post
lingual hearing impairment.
1

14. 1.1.1 Measuring Hearing Loss
This hearing impairment is measured basically in decibels hearing level
(dBHL) which will be carried by a hearing health professional. The hearing test
shown on a chart is called an audiogram. The amount of hearing loss is ranked as
mild, moderate, severe or profound.
They are as;
• Normal hearing - Hear quiet sounds down to 20 dBHL
• Mid hearing loss - Hearing loss in the better ear between 25-39
dBHL
Have difficulty following speech in noisy
situations.
• Moderate hearing loss - Hearing loss in the better ear between 40- 69
dBHL
Have difficulty following speech without a
hearing aid.
• Severe hearing loss - Hearing loss in the better ear between 70-89
dBHL
Require powerful hearing aids or an implant.
• Profound hearing loss - Hearing loss in the better ear from 90 dBHL
Need to rely mainly on lip- reading and sign
language or an implant.1
In order to overcome this impairment conventional hearing aids were used all
these years till the cochlear implant was being introduced to the world. After this
intervention almost all the people especially the parents of hearing impaired children
were very much enthusiastic of getting down the device to their children irrespective
of its high cost.
1
www.cochlear.au.com
2

15. 1.1.2 The Aim of this Thesis
This thesis mainly talks about the efficacy of Cochlear Implantation with
regard to language acquisition of hearing impaired (HI) Cochlear Implanted
(CI) children. This also deals with other supportive factors which contribute a lot
towards language acquisition of hearing impaired CI children, apart from the surgery.
This research would be helpful in making hearing impaired CI children to grow up in
a normal learning and living environment by fulfilling the other supportive factors
which would increase the efficacy of the CI in the process of their first language
acquisition. Although there are many supportive factors which should be fulfilled in
order to get the maximum benefits of a CI. This research concentrates on the effects
of the parental support, age at implantation and the rehabilitation process after the
surgery. All these three areas are being considered as compulsory factors with regard
to the efficacy of language acquisition of CI children. Nevertheless, the language
development of these CI children is also taken in to consideration. Not only that but
most of the literature reviews argue that the government too should he more
supportive in the course of supplying the CI device due to its high cost which is
being undertaken by the private sector. If the government could make necessary
arrangements to import these devices, people could be benefited.
This dissertation could be one of the early pieces of writing with relevance to
acquisition of Sinhala language in CI children, although there are so many studies
which are being handled with regard to acquisition of other languages as L1 in CI
children. Therefore, this topic covers a wide area although this particular thesis aims
at handling L1 (Sinhala language) acquisition of CI children within the Sri Lankan
context. Nevertheless, it should be emphasized that this study contains the significant
facts about language development of CI children who belong to 2-6 years of age.
Similarly, this will deal with the early development of L1 from the beginning of
receiving a CI, as it is assumed that this age limit will contribute a lot towards
making L1 acquisition effective than any other age limit with regard to all the aspects
of language like clarity, stress, intonation patterns etc. which would once again help
these CI children live in the society as normal children.
The situation of hearing impaired children in the society is very pathetic due
to loneliness and depression which arise as a result of isolation. The main reason for
this is the inability of hearing impaired children to communicate with their friends
3

16. and loved ones and mainly due to the fact that they do not have the ability to accept
their own disability. As a result to support these hearing impaired individuals the
conventional hearing aids were invented.
1.1.3 History of Hearing Aids
Conventional hearing aids invented by Alessandro Volta in 1800, stimulated
hearing in hearing impaired individuals, with an electrical current by connecting
batteries to two metal rods, which later on were inserted into the ear. Volta described
the sensation of it was similar to that of boiling thick soup which was rather
uncomfortable. Some 157 years later, the battery supplied electrical current was first
used to stimulate the auditory nerve in deafness. In the 1960 s and 70 s, great
advances were made in the clinical applications of the electrical stimulation of the
auditory nerve.
This resulted in a device with multiple electrodes driven by an implantable
receiver and speech processor, the Cochlear Implant. Due to the technological
advances of the CI the efficacy of speech perception is emphasized irrespective of
the age limit.1
1.1.4 History of Cochlear
1982 – First commercially available 22 channel implant
1985 – First to gain regulatory approval for adults
1990 – First to gain regulatory approval for children
1993 – First Auditory Brainstem implant
1994 – SPEAK speech coding strategy introduced
1996 – First implant to offer 10 year warranty
1997 – Nucleus® 24M implant released
1998 – 10,000 children with a Nucleus® implant
First multi channel BTE speech processor
1
http://en.wikipedia.org/wiki/Cochlear_implant
4

17. ACE™ speech coding strategy introduced
1999 – Only cochlear implant approved for infants at 12 months
Contour™ Electrode introduced
2001 – Over 36,000 adults and children now implanted
BTE introduced for Nucleus® 22 recipients
2002 – Our 3rd generation BTE, ESPrit™ 3G introduced
ADRO introduced to the
SPrint™ body worn speech processor
2004 – ESPrit™ 3G for Nucleus® 22 released
1.2 Objectives
Before the advent of CI, most individuals of hearing impairments managed to
maintain their auditory perception through conventional hearing aids irrespective of
the shortcomings which those hearing aids had. Although sound clarity and
intelligibility are attainable through hearing aids, they do not supply comfortable
listening. Due to these factors CI receives greater social acceptance. Although CI
was invented for the first time in 1982 it did not become very popular those days. But
from the year 2004 onwards it gained much popularity and in 2005 the first cochlear
implant took place in Sri Lanka. From that point onwards people tend to use it due to
many recommendations of the doctors. Although there was a huge trend towards CI
worldwide, it is much less in Sri Lanka in comparison to other countries, may be due
to the high cost of the device. But still one could find a fairly considerable amount of
children who have undergone this CI surgery in Sri Lanka.
1.2.1 Parental Support
5

18. Main objective of this study includes many areas connected to CI, such as
how well children with CI acquire their first language and about other supportive
factors which go hand in hand with the CI, to get the maximum benefits out of the CI
and to enable those children to intrude into mainstream education. Thereby this
research intends to compare the level of language production and acquisition with
and without much of parental support. Nevertheless, this research would once again
find out the effectiveness of first language acquisition against factors like, spoken
skills of parents, integration of the family rehabilitation programmes conducted by
speech therapists and supported by parents.
1.2.2 Age at implant
Apart from the parental support which would help to get the maximum
benefit of a CI in the process of language acquisition, this study would also deal with
the findings of the most suitable age at which the CI should take place. This
perspective of the CI would again support the fact that how well it would affect the
process of L1 acquisition in CI children.
Moreover, this would also pay attention towards the cause and age of
becoming hearing impaired with connection to L1 acquisition process of CI children.
This intends to find out how a child who has been normal in his hearing reacts after
becoming hearing impaired due to several diseases like meningitis. Here it is debated
whether a child who had proper hearing ability for some time would also become
similar in hearing impairment as a normal hearing impaired child by birth. For these
children, the efficacy of the CI in the development of oral language has shown
systematic improvement although they had had a proper hearing ability before. The
more they lack exposure to hearing sounds, the more they forget the language they
were used to. Therefore, they too tend to show more or less the same characteristics
of a hearing impaired by birth. However, further analysis of the language data reveals
that the development of L1 acquisition is not uniform across language domains as
well as in different children .This statement once again supports this thesis topic as
this too brings evidence to show that many more facts are responsible in developing
6

19. the efficacy in L1 acquisition in a hearing impaired CI child irrespective of any other
external factors like age or cause of becoming hearing impaired.
1.2.3 Language Development
With accordance to all the above factors, these CI children were observed
simultaneously to find out their developmental stages in acquiring L1. Acquisition of
language within these CI children was identified under several perspectives such as
phonologically, morphologically and syntactically. Moreover, it was tested under
audition, language, speech, cognition and communication too. Nevertheless, L1
acquisition of these CI children was investigated with comparison to language
developmental stages of a normal hearing child as it is more or less the same within
the CI children after the proper auditory input, except in post lingual hearing
impaired.1 Since most of the standard findings about language acquisition is related
to English language, those specifications were taken into consideration and were
compared with the acquisition of Sinhala language elements and investigated about
similarities and differences between those two languages.
1 .2.4 Rehabilitation Process and Strategies
Another factor which is equally important in making a CI effective in the
process of language acquisition is rehabilitation. This is mainly taken in to
consideration in this thesis as most parents have the misconception that the CI
surgery itself would totally benefit their children in acquiring their language.
Therefore, most of the parents do not pay much attention to send their HI children to
speech therapists.
Although it is intended to talk about the above facts separately, all these
factors have equal importance in the field of making a CI surgery effective towards
1
http://www.cochlear.com/files/assets/Listen-Learn-and-Talk.pdf
7

20. language acquisition. Therefore, the main objective of the present study is to lay a
better concept as to how a hearing impaired child would be benefited with a CI in
isolation and how effective it would be in providing sufficient access to auditory
speech input in acquiring language. This would also be an eye opener to the
caregivers, therapists and parents of CI children as to how and what factors should be
taken into consideration in order to get the maximum benefits out of a CI.
Nevertheless, this would provide some kind of an idea as to how these CI children
grasp and develop L1 through different stages of acquisition.
1.3 Research Problem
The area of this research deals with the possibility of developing oral
language in hearing impaired CI children. Since the language acquisition process of
these children are not uniform ,this is meant to find out the causes for it and at the
same time the possible measures one could take in order to develop this. Thereby,
this piece of writing would deal with the external factors which contribute towards
the efficacy of language acquisition, production and perception of a CI child. Firstly,
it is argued whether the CI surgery in isolation would he sufficient for a hearing
impaired child to possess normal hearing and if not what other factors should be
given prominence such as the age at implantation, the cause for being hearing
impaired, parental support and the rehabilitation programme. Above all, the
developmental process of language acquisition within these CI children also has been
taken into consideration. This would help in finding the different stages of language
acquisition of a hearing impaired CI child.
Most of the literature reviews believe on the efficacy of the Cochlear Implant
according to the age of the surgery; thereby, most of the medical officers say that the
earlier a child under goes a CI, the easier that child acquires the oral language.
Therefore, the sample data will prove the most appropriate age limit which would
enhance to gain the maximum benefits from a CI. Nevertheless, the teaching
methodology , its specifications will also be taken into consideration At the same
time the practicality of handling children with CI, the steps to be followed in
8

21. rehabilitation starting from auditory-visually which would later on can he presented
auditory alone.
1.4 Research Hypothesis
Although this study is divided into several areas like how parental support,
age at implant and rehabilitation process affect in developing L1 acquisition within
CI children, it was clearly identified that all these factors are equally important
simultaneously in order to get the maximum efficacy of a CI. Thus, HI children will
never achieve a good level of language proficiency if not for the collective effort of
all the above factors. Nevertheless, it was quite evident that the children, who receive
a CI early in life, are better in L1 acquisition than who receive it later.
1.5 Research Methodology
The sample data which is used in this research is mainly children below 8
years. These children once again could be categorized under several perspectives.
According to the objectives in this research the sample data is divided as the age of
becoming hearing impaired, whether by birth or later due to some other external or
internal factors. Apart from that the cause of becoming hearing impaired is also taken
into consideration and thereby how their levels of language acquisition vary. Another
perspective of categorizing these children is with reference to the age at CI which
would be more helpful in drawing conclusion in language acquisition of CI children.
The sample data was again categorized according to the level of parental
support and how effective the CI children acquire their first language along with that.
Nevertheless, when it comes to parental support the rehabilitation process of the
therapists also was assessed as to what factors and methods should be taken into
consideration when it comes to uplifting language acquisition, production and
9

22. perception process of a CI child. Therefore, the research methodology of this thesis
deals with the education, economy and psychological status of parents and the
teaching methods followed in rehabilitation process. These were observed in order to
figure out the efficacy of language acquisition of CI children. Particularly, almost all
the data was gained through the methods of observation, questionnaires, interviews
and focus group discussions. Focus group discussions were very much helpful in
drawing conclusions as they demonstrated great assurance in their authentic
experience which really matched with the findings too.
The age group of this research varied from 2 years to 6 years which included
children with hearing impairment by birth as well as due to other ailments like
meningitis. Some of these children had been once exposed to the normal life but they
later on got this hearing impairment as a side effect of meningitis. But they even later
on showed impairments in auditory input. They show more or less the same
deficiencies as a child of hearing impaired by birth, even they knew a set of
vocabulary earlier and led a normal life. Moreover, the tendency of forgetting the so
called earlier used vocabulary grows higher with the hearing loss since the auditory
nerve doesn’t stimulate as a normal child.
The sample was once again observed under a teaching / rehabilitation
environment at the very beginning since they were unable to produce language
spontaneously at the early stage of CI. Therefore, the L1 production of these CI
children was investigated step by step with the help of stimuli. Nevertheless, other
methods like questionnaires and focus group discussions were very much helpful in
drawing conclusions.
1.6 Significance of the Research
Significance of this research mainly lies on the focus of the acquisition of L1
in hearing impaired children with cochlear implant. Moreover, this deals with the
efficacy of it in relation to parental support and rehabilitation as well as the age at
implantation.
Language acquisition of these children is being taken into consideration with
relevant to the cause and age of hearing impairment and at the same time it is also
10

23. considered whether the age at implant creates any impact on the progress of L1
acquisition in CI, hearing impaired children.
Although this is a fact which should get social consideration and mainly the
governmental consideration due to the high cost of the CI device, it is not being
fulfilled yet. Due to the psychological impact in HI children as well as their families,
adequate measures should be taken in order to eradicate the psychological stress
which this group of people under goes.
This would also be a timely and useful study as most parents of CI children
struggle a lot in establishing proper auditory speech input within their children after
the surgery. Nevertheless, this will give proper guidance as to how people in the
society should act with relevance to hearing impaired children as they undergo
severe mental trauma due to their inability to stand on their own in the normal
society.
1.7. Conclusion
As the conclusion of this chapter, it could be stated that the rest of the thesis will deal
with all the above factors which come under objectives by using the specified
methodology. It can be also emphasized that through the findings of this research it
was easy to figure out the hypothesis clearly.
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24. CHAPTER TWO
COCHLEAR IMPLANT
2.0 Introduction
This chapter focuses on giving a brief description on the process of hearing,
the sections of an ear, hearing impairment, classification of hearing impairment,
categorization of ages at onset as in pre-lingual deafness and post-lingual deafness,
about the CI as a device and how it works in the field of supplying auditory
perception. The advent of hearing loss should be initially done by the parents, as that
affects the efficacy in every other way of a CI operation. Therefore, this chapter
would be very helpful in knowing about hearing impairment and the symptoms of it
in order to take necessary steps to eradicate the defects caused due to hearing
impairment.
2.1. Way we hear
The following details bring out a brief description about the parts of the ear and
how it works. Nevertheless, this will give a clear idea as to what disabilities make a
person hearing impaired.
2.1.1 The sections of the ear
There are three major parts to the ear and they are outer ear, middle ear and
inner ear which is called as the cochlea. These different parts work in different ways
in helping a person to have proper auditory input.
Outer ear - catches the sound waves and directs them into the middle
ear.
12

25. Middle ear - transfers sound waves in air into mechanical pressure waves
that are then transferred to the fluids of the inner ear.
Inner ear (cochlea) - turns pressure waves into sound signals that our brain can
understand.1
See  Appendix 3 (Video Clip No. 1)
2.1.2. Hearing Process
Picture 2.1 - Hearing Process
1
( http://www.cochlear.com/au/hearing-and-hearing-loss/how-hearing-works-children)
13

26. Table : 2.1 Hearing Process
1 Sounds enter the ear canal2 The ear drum and bones of
Sound waves move through the hearing vibrate
ear canal and strike the eardrum. These sound waves cause the
eardrum, and the three bones
(ossicles) within the middle ear, to
vibrate.
3 Fluid moves through the inner4 Hearing nerves talk to the brain
ear The hearing nerve then sends the
The vibrations move through the information to the brain with
fluid in the spiral shaped inner ear electrical impulses, where they
– known as the cochlea – and are interpreted as sound.1
cause the tiny hair cells in the
cochlea to move. The hair cells
detect the movement and change
it into the chemical signals for the
hearing nerve.
See  Appendix 3 (Hearing Process) (Video Clip No. 2)
2.2. Hearing Impairment
Hearing impairment is a condition which makes an individual completely or
partially impaired in detecting certain frequencies of sound. There are different types
of hearing losses. They can be categorized as conductive hearing losses and
sensorineural hearing losses. Mainly sensorinueral hearing loss can be treated
through CI. This type of hearing loss occurs mainly due to the problems in the
cochlea in the inner ear, or along the auditory nerve which leads to the auditory areas
in the temporal lobe of the brain. Heredity and diseases like meningitis are mainly
1
( http://www.cochlear.com/au/hearing-and-hearing-loss/how-hearing-works-children)
14

27. regarded as common causes for this type of hearing loss.1 Many people suffer from
hearing loss because they have damaged hair cells in the inner ear (cochlea). If some
hearing nerves still work, a CI can allow that person to hear well.2
Anyway, these various types of hearing impairments should be measured
through audiograms before any treatment. Therefore, audiologists and E.N.T.
surgeons decide on the appropriate medication for HI children or adults with the help
of the results of the audiogram.
Here is a sample set of audiograms which reveals different types of hearing
impairments:
These stages are quite clearly indicated through these audiograms
Figure - 2.1 - Levels of hearing loss
This audiogram shows 'normal' hearing.
Sounds below the lines on the audiogram can be heard.
X shows the left ear.
0 shows the right ear.
All the X and 0 are above the 20
line. This means hearing is
'normal'.
Range of hearing loss A hearing loss can be mild, moderate, severe or profound
This audiogram shows a 'mild' hearing loss.
Sounds below the lines on the audiogram can be heard.
1
Strategies for including children with special needs in early childhood settings : by M. Diane Klein,
Ruth E. Cook, Anne Marie Richardson- Gibbs)
2
(http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults)
15

28. All the X and 0 are between the 21
and 40 lines.
This is a 'mild' loss.
This is a 'moderate' hearing loss.
Sounds below the lines on the audiogram can be heard. Low/loud sounds like oo, ah,
ay and ee may be heard.
All the X and 0 are between 41 and
70.
This is a 'moderate' loss.
The hearing loss in the left ear is
worse than the right ear.
This is a 'severe' hearing loss.
Conversational speech cannot be heard. Shouting and loud noise (like traffic) can be
heard.
All the X and 0 are between 71 and
95.
This is a 'severe' loss.
This is a 'profound' hearing loss.
Speech cannot be heard. Very loud noises like pneumatic drills and planes taking off
can be heard (or felt).
16

29. The X and 0 are mostly below the
95 line. This is a 'profound' loss.
People with very profound hearing
losses can feel loud low sounds.
To work out the level of hearing loss
1. Add the Hearing Level (dB) for 250,
500, 1000, 2000 and 4000Hz in the
better ear.
2. Divide by 5.
3. If there was no response use 120dB. 1
2.2.1. Pre Lingual HI and Post Lingual HI
Hearing loss could be varied as pre-lingual hearing loss and post-lingual
hearing loss whereas pre-lingual hearing loss takes place before a baby starts talking
and post-lingual hearing loss takes place in individuals later in life. In this research
both types of hearing impairments have been taken into consideration. To diagnose
either of the hearing impairments one should be aware of the symptoms and mainly
the parents should work closely to the child since it is a silent, hidden disability. This
is mainly visible in pre-lingual hearing loss since it is something to do with babies
who cannot communicate.
2.2.2. Symptoms of HI
1
http://www.schooltrain.info/deaf_studies/audiology2/levels.htm
17

30. But still if the parents are aware of several age appropriate behaviours of the
baby, then they will easily figure out this disability. Likewise, the sample set of
parents in this research has observed some of the following symptoms which had
been useful to them in order to make early diagnosis of hearing impairments of their
children. Among them pre-lingual hearing losses have been diagnosed by some
parents due to several behavioral patterns which are not normal. One baby between
0-4 months of age has not awaken for sudden noises during the sleep. Furthermore
another parent complained about her baby who did not turn towards sounds that were
out of sight at the age of 4 months, which once again has led her to a pediatrician.
Nevertheless majority of the parents have diagnosed about their children’s disability
due to the abnormal babble sound during the age of 6-7 months. Some parents have
come across their children producing only the vowel sounds when the same age
children are far ahead in producing different sounds. Therefore these symptoms
would lead to pre-lingual hearing losses.
According to this research it contains pre-lingual as well as post-lingual
hearing impaired children. Therefore it was easy to find out the symptoms of post-
lingual hearing impaired children through their parents. Most of the post-lingual
hearing impaired children have undergone meningitis and as an after effect of that
disease they have been disabled. Thus, those parents complained about several
behaviours of their children after meningitis such as frequently asking others to
speak more slowly and loudly, turning up the volume of the television or radio,
difficulty in understanding words especially against background noise and avoiding
social settings or conversation. These abnormal behaviours have led them to medical
advice which had later on ended in CI operations.
2.3. Cochlear Implant
This part of this chapter talks about the device , cochlear implant, which is going to
be the most important part of this whole thesis, because if not for the CI none of
these severe to profound hearing loss children will be enabled to acquire language in
their life.
2.3.1 What is a Cochlear Implant and how it works
18

31. Cochlear Implant is the main issue of this thesis which from now on in this
chapter would be dealt with. A CI is a small complex electronic device which is
surgically implanted that can help to provide a sense of sound to a person who is
profoundly deaf or severely hard of hearing. This is often called as a bionic ear. An
implant does not restore or create normal hearing. Instead, under appropriate
conditions it can give a deaf person a useful auditory understanding of the
environment and help the recipient to understand speech. Thereby it would make the
recipient succeed in mainstream educational setting.
The basic implant system consists of an implanted electrode array and
receiver – stimulator and an externally worn microphone, transmitter and processor. 1
The device is surgically implanted under general anesthetic and the operation usually
takes from 1 ½ to 5 hours. Firstly a small area of the scalp directly behind the ear is
shaved and cleaned. Then a small incision is made in the skin just behind the ear and
the surgeon drills into the mastoid bone and the inner ear where the electrode array is
inserted into the cochlea.
After 1-4 weeks of healing, the implant is turned on or activated. Although it
is activated, as most of the parents expect, results are typically not immediate since it
needs time for the brain to adapt to hearing new sounds. During this period post-
implantation therapy is required with the fullest effort of parent –professional
involvement.
When we talk about the CI as a device and its operations it is a very complex
process. All cochlear implants have two main components out of which the internal
component is implanted as it is mentioned earlier, where as the external component
is worn outside. The external component consists of a microphone, an external
transmitter and a signal processor or referred as a speech processor. The microphone
picks up sound from the environment. The speech processor then selects and
arranges sounds picked up by the microphone. The internal component too plays a
major role as the external component. Since the internal component consists of
electrodes that are implanted into the cochlea, they collect the impulses from the
stimulator and send them to the brain. The incoming sound is analyzed by the signal
processor and computed into fundamental acoustical information. These represent
the key elements of human speech.2
1
(Amy Mc Conkey Robbins)
2
( (Leading Article Cochlear implants in children Devanand Jha1 Sri Lanka Journal of Child Health,
2005; 34: 75-8)
19

32. 2.3.2. Parts of a CI
Picture 2.2 - Parts of a CI
1. A sound processor worn behind the ear or on the body, captures sound and
turns it into digital code. The sound processor has a battery that powers the
entire system
2. The sound processor transmits the digitally-coded sound through the coil to
the implant
3. The implant converts the digitally-coded sound into electrical impulses and
sends them along the electrode array placed in the cochlea (the inner ear)
4. The implant's electrodes stimulate the cochlea's hearing nerve, which then
sends the impulses to the brain where they are interpreted as sound.
2.3.2.1. Cochlear implant components
Picture 2.3 : Parts of a Cochlear
20

33. Sound Processor
Implant1
See  Appendix 3 (Video Clip No. 3) (Parts of a CI)
2.3.3. The benefits of a cochlear implant
Many adults with cochlear implants report that they:
• Hear better than with a hearing aid Study showed an average 80%
sentence understanding, compared with 10% for hearing aids1
• Can focus hearing in noisy environments Converse with people across
meeting tables, in restaurants and other crowded places
• Reconnect with missed sounds The sound of the rain
• Feel safer in the world Hear alarms, people calling out and approaching
vehicles and know where they are.
• Talk on the phone
• Enjoy music
1
http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults
21

34. 2.3.4. Factors which affect the benefits of a CI
• How long they have had hearing loss
• How severe their hearing loss is
• The condition of the cochlea (inner ear)
• Other medical conditions
• Practice using their cochlear implant system1
2.4. The CI surgery
Although we talk about the cochlear implant surgery as the basic need to acquire
language within these HI children, there are so many other factors which should be
completed before the surgery. These steps could be basically categorized as pre
operative stage and post operative stage, where pre operative stage pays a great deal
of attention to find out the eligibility of the HI child for the surgery and the post
operative stage deals with the checking of the auditory level of these HI, CI children
and about their rehabilitation programmes.
2.4.1. Pre operative evaluation of a CI
When we consider a CI operation, preoperative evaluation is given much
prominence since the progress of the whole surgery depends on this and nevertheless
it assures the child’s health security even after the operation. Therefore, as
preoperative preparation selection of candidate, radiological assessment,
psychological and social consideration is taken into consideration. Moreover plans
for postoperative operations are also being discussed and planned out before the
surgery since it too plays a major role in the process of L1 acquisition within a
hearing impaired CI child. Therefore, postoperative preparation contains surgical
procedure and rehabilitation programming.
1
http://www.cochlear.com/au/hearing-loss-teatments/cochlear-implants-adults
22

35. A surgeon (E.N.T), an audiologist, a speech-language pathologist and a
teacher for the deaf are responsible for the candidate selection since it is a
multidisciplinary evaluation.
Figure 2.2 - OAE Report
This is a pre operative evaluation of a HI, to check the functions of the
cochlea.
2.4.2. Candidacy Selection
23

36. There are several factors that determine the degree of success to expect from
the operation and the device itself. Therefore candidate selection takes place on
individual basis. Thereby a person’s hearing history, cause of hearing loss, amount of
residual hearing, speech recognition ability, health status and family commitment to
aural rehabilitation are considered before a CI surgery.1
The selection criteria for inserting a CI in hearing impaired children are as
follows, those children should be twelve months of age, however, even before one
year of age a child can be implanted when meningitis is the cause for the hearing loss
since meningitis causes ossification in cochlea as time passes rendering electrode
insertion more difficult. Moreover a child should suffer from bilateral sensorineural
hearing loss and at the same time that child is not benefitted from hearing aids. Thus
the child should be checked for medical contraindications before the surgery. This
brings only a brief set of criteria for candidate selection whereas it is a very
complicated matter.
Not only the physical perspective of the candidate but also the psychological
perspective of the candidate should be examined before the operation. Thereby once
again it shouldn’t only be of the candidate but of the parents and other family
members too since they have a vital role to play after the operation which would
influence a lot in the efficacy of L1 acquisition.2
See  Appendix 3 (CI surgery – DVD No. 2)
2.5. Factors which influence the efficacy of L1 acquisition in CI
children
There are so many factors which influence speech recognition by children
with CI. All these facts are responsible for the efficacy of L1 acquisition in CI
children. They are,
1
http://en.wikipedia.org/wiki/Cochlear_implant
2
(Devanand Jha)
24

37. 1) Implant technology.
2) Surviving neural population.
3) Auditory (sensory) deprivation.
4) Auditory pathway development.
5) Plasticity of the auditory system.
6) Length of deafness.
7) Age at time of implantation.
8) Etiology of deafness.
9) Preoperative selection criteria.
10) Preoperative hearing level.
11) Preoperative auditory speech perception.
12) Measures of speech perception.
(preoperative and postoperative)
13) Preoperative linguistic level.
14) Other handicaps.
15) Surgical issues.
16) Device programming.
17) Device/equipment malfunctions.
18) Mode of communication.
19) Auditory input.
20) Frequency type of training.
21) (Pre) school environment /education setting.
22) Parental/family motivation, social issues.1
Although CI surgery is regarded as only one process on the surface level, it
includes several other areas to be fulfilled, which are mentioned above to get the
maximum out of a CI in a hearing impaired individual. Still most of the issues
mentioned in the above list are beyond the scope of this research, this would deal
only three factors which would influence the efficacy of L1 acquisition in hearing
impaired CI children such as age at implantation, parental support and rehabilitation
programmes.
1
Amy Mc Conkey Robbins
25

38. 2.6. Conclusion
This chapter dealt with a brief idea of what is meant by hearing impairment,
how to figure out this disability in the stages of pre-lingual and post-lingual hearing
loss, about the cochlear implant as a device, how it is being inserted, pre and post
operation management of a CI etc. Since this describes as to how a parent could
figure out the earliest stages of his/her child’s disabilities it would be very much
important to get the earliest treatment as possible since it would maximize the
efficacy of L1 acquisition of that HI child with proper medical care and nevertheless
this child will not be left alone in the society since he/she can educate in the
mainstream schools which would once again be a supportive factor in the growth of
his/her personality development.
26

39. CHAPTER THREE
SUPPORTING FACTORS
3.0. Introduction
This chapter deals with some of the supportive factors which would influence
the efficacy of L1 acquisition in hearing impaired CI children apart from the medical
therapy these children get. Under these supportive factors, the effectiveness of L1
acquisition is measured according to parental support, rehabilitation process and the
age at implant. With regard to both parental support and rehabilitation there should
be proper sequential order which would be compatible with the implant age of a CI
child. Therefore, many audiologists have done several researches and have come to
conclusions as to how these CI children should be rehabilitated. This chapter gives
an overview of these methods which are being adopted by the therapists in their
therapy sessions and how far they have motivated the parents of these CI children to
help their children. Simultaneously, almost all the facts show some kind of
development with regard to early age at implant. All the developments with CI
children who received their CI as early as possible show a speedy development in L1
acquisition, while the other CI children reach that level with much more time
consuming. Nevertheless, it should be insisted that most of the researches with
regard to CI children language development are handled associating English
language, but this thesis has made use of all those theories in such a way which
would relate to Sinhala language, as the L1 of the sample set of CI children belongs
to that.
3.1. Parental Support
Firstly, it is intended to discuss the fact of parental support and how effective
a CI child acquires his or her L1 with the help of the parents. This should not only be
the parents but it could be the responsibility of other family members and close
friends too. This is more important mainly in the field of psychosocial, in the process
27

40. of socializing HI, CI child. Therefore, although the main aim of this research is to
figure out the efficacy of language acquisition in hearing impaired CI children, the
behavioural patterns of the parents of these CI children, their economical status, their
level of education, their ability in psychological adjustments and their social status
were taken into study. Those data were later on analyzed and compared with the L1
acquisition of CI children and thereby it was easy to draw conclusions as to how
parents with hearing impaired children should act to get the maximum benefits of a
CI apart from a successful surgery. Therefore, this would surely be an eye opener to
those parents who are really enthusiastic of intruding their HI children into
mainstream education.
From the beginning of this research the importance of the parental involvement
was very significant since they have given their children proper medical care.
Almost all the parents involved in this research, have taken proper decisions at
correct time due to their keen observation irrespective of their social status and the
level of education. Nevertheless, although most of the parents in this sample study do
not obtain a higher economical state, they have somehow or the other managed to
cover the high cost of this CI surgery which in one way seems very pathetic. This
situation once again creates great impact on the efficacy of L1 acquisition in HI child
although it doesn’t seem directly. Some parents were really honest at moments when
they came out with their real emotions which have suppressed them due to the heavy
cost of the CI and therefore they rather regret in neglecting their children in the
rehabilitation programme. This is mainly due to their inability in positive stress
management. Therefore, as postoperative measures of a CI the parents with CI
children too should be provided with regular counselling programmes according to
their level of education. Although some parents with CI children are highly qualified,
they lack the ability to cope up a situation like this throughout their life span since
this would ultimately become a real burden handling a CI child in a family. This
chapter identifies the stresses of parents with CI children, tied directly to the situation
and talks about the psychological adjustments which should be altered within them.
This problem should be solved in such a way since it affects the process of L1
acquisition in HI, CI children due to the lack of attention they get from their parents
and other family members who have undergone lot of mental trauma. Therefore,
mental up liftment programmes for these parents, should be implemented by the
28

41. health sector simultaneously with the CI operation in order to make the CI children
grasp their L1 more effectively.
3.1.1. Responsibilities of these parents at different levels
When we consider the involvement of parents toward these CI children, it
begins from the point at which they diagnose the disability of hearing impairment of
their child, which could be categorized as pre-lingual hearing loss and post-lingual
hearing loss. The symptoms which led them to recognize their child’s disability were
stated in chapter two. Therefore, the necessity of proper parental care is very much
evident in every aspect of this cochlear implantation .Thus this chapter focuses on
bringing out the importance of proper involvement of parents with CI children to
raise the efficacy of language acquisition within their children.
The involvement of parents could be observed step by step from the time of
diagnosis and giving them proper medical therapy rather than ignoring the disability
in order to maintain their social level. Once their children are taken to an E.N.T.
surgeon, it is the parents who have to face the crucial stage of finding the high cost
needed which they find it with much effort ,being citizens in a third world country
like Sri Lanka.
Then they have to have proper education in order to understand the
advantages as well as the disadvantages of this operation since there are so many
irreversible points after an implantation. Therefore the parents should be informed
about them and should negotiate with them in order to know whether they are ready
to take the risk.
Even just after the operation the parents of CI children should be well
informed about the steps they should follow with regard to the incision where they
have to keep the wound dry for the first few weeks before the implant is activated.
They should be well aware of the times they have to shave behind the ear of the CI
child in order to fix the speech processor.
Nevertheless, the parents should be educated enough to understand the
instructions given by the manufacturers of the CI device as they have mentioned so
many cautious situations .The parents should pay attention to follow the given
instructions in bathing the child, when in sleeping and so on. During these instances
the parents should be conscious of turning off and removing the external component
of the CI. Nevertheless, those instructions mention about several restricted activities
29

42. like scuba diving, going near strong magnets etc. Therefore, parents always have to
be very vigilant about their children’s behaviour since they are small.
The charging of the battery according to the device is another process which
most of the parents find it difficult to follow due to various reasons such as
standardized measures of depression, time demands, lack of common sense,
illiteracy, anxiety etc.
Considering the rehabilitation programmes, it is the parents of these CI
children who should come in forward to get the necessary steps to be done to their
children. But still most of the parents of these children are in problematic state in
finding proper teachers for the deaf.
They are in trouble in selecting a teacher or a suitable programme for their
children since most of them tend to depend on the information they get from their
friends who have got children with the same deficiency. But these parents do not
realize that this is a surgery which does not give uniform as well as quick results
and therefore they try to compare their CI children with their friends’ children which
is something shouldn’t be done. Once again it should be the responsibility of the
personnel in the medical field to educate the parents with CI children, about the time
expansion that will take to get visible improvement in L1 acquisition after the
operation. Otherwise it is more natural of them to have high hopes about the recovery
of their child’s disability.
When we consider parental support, it was observed that the involvement of
mothers was higher to that of fathers in the field of improving L1 acquisition in CI
children. Moreover the findings showed the level of expectations of these mothers is
somewhat high irrespective of the slow rehabilitation process. Therefore they tend to
force the professionals or the teachers for the deaf, regarding the language outcomes
of these CI children. It is identified that the cause for these types of behaviours takes
place due to their higher level of stress and high expectations. Thus it is thoroughly
suggested that the parents of these CI children should be rehabilitated before
anything else if the society intends to make the CI children acquire their L1 more
effectively.
In the matter of handling the CI device it was identified that most of the
parents still have not got a proper understanding about its operations, which would
definitely influence the efficacy in L1 acquisition of CI children. Although these
points are to be considered as minute details, they play a vital role in the efficacy of
30

43. L1 acquisition since these operations and handling the device properly comes in the
basic position. Even most of the well educated set of parents with CI children , said
that they still could not follow all the instructions with regard to charging the battery
and with regard to handling the device in various manner in different situations.
Therefore, to overcome such issues those parents should be given those instructions
in their mother tongue or there should be a demonstration as to how they could
follow the instructions easily rather than just making profit by selling the product. Or
else they could print out the instructions in Sinhala and Tamil too and give them to
those parents.
Due to the higher level of stress and poor psychological adjustments
experienced by the parents of CI children, lack of auditory input takes place which
once again poses additional threat to optimal development of a CI child. According
to this study it was observed that the whole sample of parents were of normal hearing
whereas the children were deaf. Therefore mostly these hearing mothers tend to
engage in more controlling, directive actions with their children rather than being
more likely to respond to their behaviour. Moreover the available evidence through
this research indicates that although a CI child requires some level of effective
communication with the parent, it is not being fulfilled most of the time, mainly
due to the mismatch between the deaf child and the hearing mother. This becomes a
significant barrier throughout the life span of them and as a solution for that, these
mothers seek the help of some professionals which once again does not become
successful since the CI child is not being educated in a stress free environment. Due
to their aggressive violent behaviour they are being controlled in such a manner
which once again make them inhibited to grasp their L1. Thereby the CI child tends
to feel these ill treatments and emotionally upset. Therefore not only the parents but
also the caregivers and professionals should be aware of showing them some
maternal sensitivity rather than being controlling them all the time although they
misbehave.
Furthermore it was identified that the parents tend to avoid talking to their CI
children as time goes on, since they need much patience and time to tell them
everything in a slow manner. These types of negligence mainly take place due to the
responsibilities of other normal children in the family. Most of the parents with CI
children pay their fullest attention during the first few months of the surgery but after
that they fall into a lethargic condition which is something very pathetic from the
31

44. point of view of the CI children. Therefore this tendency should be eradicated from
our society even by increasing the quality of rehabilitation programmes or by
training caregivers with full of sensitivity. Otherwise none of us can predict about the
future of these CI children positively.
3.1.2. Parental Support Towards L1 Acquisition
Moreover, they have the responsibility to train their children to acquire
language too. Therefore, the following tips would be very helpful in teaching their CI
children at home. Although this guide is there, some of the parents should be
educated by the therapists as well which would appeal according to their level of
education.
When it comes to parental involvement towards the L1 development in CI
children, once again this language developmental process could be initially divided
into two sections. Basically, L1 development of these CI children begins with the
audition and the input of it should be strengthened. Therefore, these parents should
be made well aware of these developmental stages. Likewise, the therapists should
assist these parents and should assign them with specific area of sounds that they
should work on within a period of a day or two. Then the therapists can observe how
far these CI children have grasped the sounds and move on to another step. This
method was observed within the sample set of this thesis and drastic developments
could be observed.
3.1.3..Tips for Auditory – Verbal Therapy at Home
The following details of this chapter basically deal with the therapy which
parents at home can handle as they spend more time with their CI children. These
small activities could be done formally and at the same time as informally in order to
enhance the CI children grasp their L1 quickly. Although one could see these
activities as very simple, they affect a lot in L1 acquisition process in CI children.
Therefore, these activities should be promoted by the speech therapists and
audiologists apart from their rehabilitation programmes.
32

45. 3.2.3.1. Tips for formal Auditory – Verbal Therapy lessons at home
1 Children learn through play.
2 If it is not fun for you or your child, they will not cooperate or learn.
3 Make Auditory Verbal Therapy a 24 hour time for teaching.
4 Know your goals for the week so that you can incorporate them in
everything you do
5 Sneak short lessons into the daily routine, e.g. 30 seconds for covering
one goal " Do you own the pink tooth brush or the blue one"
6 Wait for your child's response signal expectation of an answer by tilting
your head and raising an eyebrow.
7 Join in on your child's most favourite game and describe direct action and
discuss as you play.
8 Model and expand your child's utterances with additional language and
correct grammar if he says “truck" you could reply " It's big truck .Look
at the big wheels. I like that big red truck".
Instead, we as Sri Lankans can make use of the word “bus” for
this because these CI children are not familiar with the word “truck” and
further it was identified that these Sri Lankan CI children are not that
efficient in producing this retroflex /r/ sound, especially at the very
beginning of L1 acquisition. Later they can be made familiar with some
added adjectives like /loku/ (big) and then both together as in /loku bas /
or /loku bas ekə/ (a big bus). Next they have used some phrases with
regard to wheels, which is once again difficult for a Sinhala speaking
child to produce /roɖəjə/. Therefore, it is advisable to talk about the
length of the bus as /ɖigə/. Accordingly, necessary changes were adapted
to suit CI children whose L1 is Sinhala.
9 Reward appropriate behavior with your attention and discourage
inappropriate behavior by ignoring it. " Good talking I like the way you
said " truck"
10 Read at least 2 books a day – 100 books a day if possible
33

46. 3.2.3.2. Tips for informal Auditory Verbal Therapy opportunities at home
1 Fold the washing
Sorting for young children can be based on using the possessive
's" e.g. " These are Daddy's Pants.
Accordingly, the sample set of CI children were more
comfortable when it was said ; /mɑge:/ (mine), because if the words
mum’s or dad’s are directly translated into Sinhala they won’t be the
same as one syllable. Therefore, these CI children will be confused. It
takes some more time with Sinhala speaking CI children than it is with
English speaking CI children when considering this point as these
children find it difficult to produce possessives like /ɑmmɑge:/ and /t
:ttαge:/.
2 Another way of sorting is by colour pattern (checks, stripes etc) Length
of sleeves, pant leg etc.
3 Matching pairs put 6 or 8 socks our and ask which ones are the same/
nor the same Ask for a certain sock of the group if an older child. Can I
have the sock that has stars around the top?
This point basically deals with commands where these CI
children are being motivated due to the ease of saying these short
phrases such as /maʈə dennə/ (give me). Initially, they will come out
with only the action word (/dennə/)- (give) while they later on manage
to come out with other words.
4 Wh questions can also be used as ways of sorting .Which pile do these
go on? Where do these go? Who wears these socks? Whose socks are
these? What are these gloves for?
Although, these kinds of questions are proposed for the early
development of CI children it was investigated that the CI children in
this sample data found it more complex may be due to the language
differences.
34

47. 5 Plurals can be targeted "Put all the socks here. How many hankies are
there?
When it comes to this type of scenario these CI children will
answer giving the number but it is once again debated whether it suits
the situation. For example normal Sinhala speaking children will
answer that kind of question as /pɑhɑi/ but these CI children will
say /pɑhɑ/ which denotes only the number but does not give any
implication about the relevance to the situation. This is once again
different from English language, because in English it is just /fɑiv/. It is
the same as the number unlike in Sinhala.
6 Putting clothes away can be used as a way of following directions" Put
these socks in the top drawer" Prepositions such as next to between,
beside, behind in the corner, underneath and many more can be used.
7 Directions can be changed from simple to complex put the socks in
daddy's cupboard in the second drawer.
8 Sabotage makes the session longer “These socks go in the bottom
drawer beside the hat isn’t the hat in that drawer? Look in the drawer
above that one is the hat in there?
Setting the Table
1 Possessives again can be covered" This is Mary’s fork"
2 Simple and compound sentences can be used as directions “Put the
fork next to the napkin put the knife and spoon on the right and the
fork on the left.
3 In a bottom drawer in the kitchen, have a plastic cup, bowl and plate
“Get out the cup. Get out the bowl and the cup. Get out the cup but
not the plate." Increase contents of drawer to having a cup, bowl and
plate in 3 colours. “Get out the blue plate and the red cup."
4 Napkins can be folded to make rectangles. Squares and triangles.
Once again in Sinhala the words which relate the shapes are
very complex. Therefore, they are not given much prominence in
35

48. speech but given in picture matching sessions and object matching
sessions.
5 Sabotage again can be used to promote language. E.g. forget to have
chairs at the table to put out food on the plate.
6 Have a plastic animal at the table or on the high chair. Give the toy
animal something to eat as well as your child. Talk to the toy as you
would to the child.
As stated above, different changes to these situations were made in order to
suit our Sri Lankan context and Sinhala language.
Sitting in the car
1 Singing songs loudly. A tape of preschool songs could be made at music
session at preschool next time.
Under these they were made to listen to songs with easy words
and with sets of repetitive words.
2 Get you older child to tell you which way to go " Turn left over the bridge
Go straight ahead turn at the next corner, " Follow their directions and
even make a mistake when you know what they say is wrong. They will
learn to give specific directions.
3 Time words can be used. Before I start the car, put on your seatbelt while
we are in the car we look for traffic signs. After we go to the shop, we
will go the petrol station.
Waiting at the doctor
1 I spy with my little eye something that people sit on.
2 I'm thinking of something that has 4 legs. It is made of wood, it has books
on it
3 I’m thinking of something in our kitchen it is white and cold on the inside
it has a big door etc.
36

49. 4 Hum a song "Can you guess what it is?" (Keep it simple at first)
5 Have 5 small stones. Close up hand. “How many stones?" Give a quick
look and close up hand again. Vary the number in your hand.
6 Take favourite books to read together.
7 Play what's missing? Take 3 toys from the toy basket cover with a scarf
take one away without letting the child see it.
8 Draw shapes on bigger child's back. Guess which shape it is.
Taking a Bath and Swimming
Language opportunities can be lost at bath time and when swimming, because
the child cannot wear amplification. Create the language opportunities at a different
time. Use a bowl of water and wash a dolly as you would do to your child. The child
then will replay those games himself in the bath.
1 Talk about body parts
2 Use action verbs
3 Using verbs
4 Talk about hot/ cold, wet/dry, in/out, under/over, back/front, floating/
sinking etc.
Washing the Dishes
This takes on new meaning when it is done in a bowl with warm water outside
1 Item selection can be done
2 Following directions
3 Maths concepts can be tested e.g. measuring volume, height, number
of animals in a boat before it sinks, etc.1
Although all these parental activities are given according to CI children
whose L1 is English, we being Sri Lankans can adapt changes to them in order to suit
our culture and language. Therefore, some of the adjustments were made accordingly
1
Hear and Say Center
37

50. as they were used throughout this research. At the same time it is going to be another
challenge for our parents as they have to be mindful as to how they are going to help
these CI children to develop their acquisition level. Nevertheless, through these tips
one could easily realise the work load or the level of commitment of the parents of
CI children in order to make their HI children acquire language more appropriately.
Once they become use to these they can automatically engage their CI children in
day to day activities by giving them opportunities to expose themselves to language.
Therefore, the CI users should be given constant proper guidance in the
process of localization unlike a normal hearing child .This is also should be
supported by parents. And these CI children should be trained to localize sounds
which would later on make them localize alone when they get familiar to that action.
For this, parents of CI children should make use of almost all the opportunities in
their surroundings.
See - Appendix 3 – Video Clip No.4 - LLT1.f4V (Speech Therapy)1
3.3 –Rehabilitation Process
Furthermore, the rehabilitation process which should take place immediately
after the CI also contributes a lot in developing the spoken ability of a CI child. The
rehabilitators should always have good rapport not only with the CI children but it
should be emphasised that they should have prompt connections with their parents,
audiologists and the E.N.T. surgeons who are responsible of handling each CI child.
Nevertheless, these speech therapists should be qualified enough to handle these CI
children as they should be well aware of certain theories which are connected to
language acquisition of normal as well as HI children and the teaching approaches
and strategies with relevant to these CI children’s psychology. Therefore, this
chapter will also deal with the most appropriate teaching methodology and the
strategies which could be incorporated in teaching CI children.
When we talk about the methodology of teaching CI children one could
assume that these methods and activities do not match our Sinhala language and our
culture. But most of the therapists who trained the sample set of CI children made
1
http://www.cochlear.com/files/assets/videos/LLT 1.f4v
38

51. use of these methods very successfully in order to match our children. This gave
great results in L1 acquisition.
3.3.1. Developing listening skills in CI children.
The L1 development starts from listening first. Therefore, there were so many
strategies which these therapists used in order to give a proper auditory input in these
CI children. But before all these, CI children were tested by the audiologists for their
proper audition levels after receiving the CI. This is very important for the therapists
in order to develop the L1 perception within these CI children. Therefore, a brief
explanation as to how it is tested is given below.
3.3.1.1. Testing Listening Skills
Initially, just after activation of the implant these CI children should be tested
for their auditory input. This is done under several medical and physical observation
assessments.
When we talk about measuring their auditory levels they were checked under
a specimen audiogram which is called as speech banana which includes all the
possible speech sounds under several frequencies .This is called the aided hearing
test and here are the following illustrations of them.
39

52. Figure 3.1 - Model of the aided audiogram
Nevertheless, these children are once again tested for their listening levels
through their behavioural patterns and through their reactions in several stimuli based
situations. For example, if they have reached the proper auditory input level they
were able to turn their head towards the direction of the sound.
40

53. With the help of these results speech therapists decide on the adjustments of
the implant and if not necessary they will immediately begin speech therapy in order
to make the CI child grasp his or her L1 without any delay. Speech therapists first
observe the levels of listening skills with implant age. Therefore, it is very essential
to know about the standard abilities of CI children in order to make them achieve
different stages.
3.3.1.2. The Sequential Development of Listening Skills
The following table gives an overview of implant-age appropriate listening
skills, but it should be noted that these levels were not the same among every CI
child as most of the CI children demonstrated so many differences in various
perspectives mainly due to other disorders within them apart from the hearing
impairment.
Table 3.1 - Cochelear Implant Listening Skills Development
Cochelear Implant
Listening Skills Development
Guide to Rate of progress
Development timings are only indicators and will vary according to the number of
factors.
1-4 weeks after Stage1 of • Awareness of voice
switch-on Awareness • Awareness of environmental sounds (able
Sound to localize sound)
• Detection of ling sounds ('a', 'ee', 'oo', 'm',
'sh', 's')
• Respond to own name (through listening
alone)
From 1-3 months : development of
discrimination/ identification** of Ling
sounds
**Discrimination : the ability to perceive
difference between two or more speech
sounds.
Identification : the ability to recognize a sound
by repeating, pointing or writing what is
heard.
2-5 afterMonths Stage 2 Pattern perception and non-language aspects
Suprasegmental of speech
41

54. switch-on Discrimination • Distinguished changes in vocal length
and (duration : long & short)
Association • Discriminate intensity/ pitch (loud & soft/
high & low)
• Perceive difference in intonation/ stress/
rhythm/ rate
• Imitating learning to listen sounds (Dog-
woof, Cow-moo)
• Perceive difference in word length (123+
syllables)
• Discriminate sentence length (short phrases)
6-9 months Stage 3 Follow developmental steps for listening
after Segmental language and speech (refer to Listen, Learn
switch-on discrimination & Talk, Cochelear 2003)
& Association • Discriminate constant and vowel difference
in 1, 2 & 3 syllable words (ball. Apple,
dinosaur)
• Discriminate between increasingly similar
words;
 Consonant same, vowel different (boat,
bat, bus; cat, coat, car; hat, hit, hot)
 Constant different only by manner
(house, mouse; bat, mat; far, sat)
9-18 Months Stage 4 Identify:
post- Identification • 1 keyword in context, with & without
implant suprasegmentals
• 2 key words in context, in one sentence
• 3 key words in context, in one sentence
• 4+ key words in context, in one sentence
18+ Months Stage 5 • Advanced vocabulary development
post- Progressing & (expand categories, abstracts)
implant Comprehension • Increase word play association through
listening
• Answer simple questions (where, what,
who)
• Understand increasingly complex sentences
with 3+ elements
• Listen to short paragraphs and answer
simple questions
• Answer complex questions (how, why,
what, next)
• Listen to longer paragraphs and answer
complex questions
• Sequence with and without visual support
like pictures and cards
42

55. • Increase cognitive language skills (more
complexity)
• Follow conversation with familiar topic
• Follow open-ended conversation (topic
unknown; unfamiliar speaker)
1
With some kind of understanding about these stages the speech therapists
involve in teaching listening with the help of parents. Therefore, the following
strategies are being followed.
3.3.1.3. Teaching Techniques and strategies to develop listening skills
• Be within hearing range. Sit on the child's better ear. Ensure you are speaking
on a level opposite to his/ her hearing aid.
• Start with easy to hear sounds.
• Have extensive experience through play
• Have high expectations expect that the child will hear
• Parents must take part in the therapy sessions so that they learn what to do
and can also be used as models for example, stimulus response activities it is
necessary to have two adults when teaching the child the one making the
sound must not respond; turn taking skills can be developed by using parents
as models.
• Auditory input first the spoken input is given before the toy / item is seen or
before the toy moves.
• Encourage children to vocalize before the toy moves or before they have their
turn.
• If the child vocalizes when working with toys and associated sounds, reward
him/her by giving him/her the toy and then repeat the sound again to
reinforce.
• Have lots of repetition built into the game/activity.
• Parents need to be given ideas for reinforcing in home setting so that
meaningful interaction occurs.
1
Adapted from Shepherd Centre notes, Immediate AV course 2003 and from Childrens's Hospital,
Oakland, Rate of Progress – Hear now And always CochlearTM
43

56. • Do a range of activities in a session to give parents a variety of ideas but let
them know that they can spend a lot time on the one activity when playing at
home.
• Younger children can't play and listen. They can be rewarded after they have
listened by playing with the toys. When they are older and good listeners they
may be able to do both.
• Integrate cognition – Even though a child's language and speech may be
delayed, she can be challenged cognitively.
• A barrage of auditory information is necessary before the child sees the
object. Present the object in an interesting way so that there is the opportunity
for a lot of repetition.
• Allow time for the child to respond it is necessary to allow processing time
• Change suprasegmental features – this makes the input more auditory
available.
• Move closer to the microphone and speak softly if there is difficulty with a
particular sound not too close however and too close however and remember
to use a quieter voice.
• Don't have distracting noises when talking e.g. noisy toy.
• Don't test very young children check incidentally whether meanings are being
associated and identification skills are developing.
• Achieve goals through play – However in the formal lessons it will be
contrived play.
• Have short term and long term goals.
• Choose age and stage appropriate materials and activities which are
interesting. Challenging and meaningful.
• Establish age appropriate expectations for behaviors expect compliance.
• Always be mindful of extending the child go one step further (Greater M.I.U.
etc.)
• Be mindful of extending both receptive and expressive skills.
• Capture the child's attention.
• Provide plenty of opportunity for the child to respond and expect him/her to
respond to communication attempts – this is necessary to build up the ability
44

57. to interact and is a part of conversational competence.
• Expect closer and closer approximations until the target is consistently
produced.
• Provide plenty of opportunity for the child to respond.
• Correct through audible contrasts to less audible ones.
• Acoustically highlight to help a child hear a contrast but remember to put it
back into natural rhythm.
• Progress from more audible contrasts to less audible ones.
• If you're unsure whether it's the listening or the conceptual aspect the child is
having difficulty with have him her repeat what you are saying.
• It is important for the teacher/therapist to learn to listen.
• Integrate speech work into everything.
• Don't interrupt child when speaking but if she leaves off a sound, for
example, that you know she can do, then when she has finished talking,
practice in speech babble and then put this back into the word and then into
the sentence,
e.g. us us us – bus bus- on the bus. 1
The above document brings some kind of curriculum in aiding listening skills
within CI children. There were so many instances when therapists used most of these
strategies in order to make these CI children aware of the sounds and due to that it
was quite evident that they responded very well to some of the sounds within few
weeks after the implant, but at the same time it was observed that whenever some of
the CI children did not attend these rehabilitation programmes regularly they did not
demonstrate much of an improvement in sound perception.
Apart from these theories Ling-6 sounds has become another effective theory
which has been identified through several researches. Therefore, these Ling-6 sound
theory too was used by the therapists throughout this research in order to make these
CI children aware of the sounds around them.
3.3.1.4 Signalling language acquisition through sound perception
1
Ref ; S. Romanik.October 1997
45