Summary of the Clinical Practice Guideline

Article Citation

Royal College of Speech & Language Therapists Clinical Guidelines: 5.7 Deafness/Hearing Loss

Taylor-Goh, S. (ed). (2005).
Bicester (United Kingdom): Speechmark Publishing Ltd., 53-61.
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Sponsoring Body

Royal College of Speech & Language Therapists (United Kingdom); Department of Health (United Kingdom); National Institute for Clinical Excellence (United Kingdom)

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Article Details

Description

This evidence-based guideline provides recommendations for the assessment and management of communication impairments caused by deafness or hearing loss in children and adults. This guideline is intended for speech-language pathologists.

Evidence Ratings for This Document

Recommendations are classified into one of three categories based on the strength of the supporting evidence, which are further defined as follows:

  • Grade A Evidence: includes "at least one [randomized] controlled trial as part of the body of literature, of overall good quality and consistency" that addresses the specific recommendation (p. 387)
  • Grade B Evidence: includes "well-conducted clinical studies but no [randomized] clinical trials on the topic of recommendation" (p. 387)
  • Grade C Evidence: indicates the absence of "directly applicable studies of good quality" and is from expert committee reports on opinions and/or clinical experience (p. 387)

Recommendations from This Guideline

What are Recommendations?

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Assessment

In addition to gathering information about medical history, the clinician should consider collecting the following case history information:

  • age at diagnosis, type, nature, and etiology of hearing loss;
  • age at intervention;
  • audiological test results;
  • type of amplification, age at fitting, and consistency of use (if applicable);
  • recommended hearing aid settings and use of environmental devices (if applicable);
  • first language, including sign language;
  • preferred language, including sign language, manually coded English, cued speech, gesture, and speech;
  • level of speech reading competency;
  • other audiological/vestibular symptoms (e.g., tinnitus, balance impairment);
  • need for an interpreter; and
  • links to Deaf community (Grade C Evidence).

Keywords: Case History, Case History, Case History, Case History

"The individual's ability to use their aided hearing for functional listening in everyday home, school or work environments should be assessed" (p. 54) in addition to their aided ability to detect, discriminate, and identify environmental and linguistic sounds (Grade C Evidence).

Keywords: Educational/IFSP Considerations, Educational/IEP Considerations

The clinician should evaluate speech reading abilities at the single word and connected discourse levels with consideration for visual and auditory-visual strategies (Grade C Evidence).

Keywords: Speech Reading, Speech Reading, Communication Modalities, Speech Reading, Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language

"Post-lingually deafened adults and some, but not all, school-aged deaf children may require assessment with closed-set speech perception materials" (Grade C Evidence; p. 56).

Keywords: Speech Perception, Speech Perception

Treatment

Clinicians should collaborate with others to adapt the physical, social, sensory, and linguistic environment to enhance language and communication accessibility (Grade C Evidence).

Keywords: Aural (Re)Habilitation, Environmental Modifications, Speech-Language Intervention, Educational/IEP Considerations, Environmental Modifications, Aural Rehabilitation

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Assessment

In addition to gathering information about medical history, the clinician should consider collecting the following case history information:

  • age at diagnosis, type, nature, and etiology of hearing loss;
  • age at intervention;
  • audiological test results;
  • type of amplification, age at fitting, and consistency of use (if applicable);
  • recommended hearing aid settings and use of environmental devices (if applicable);
  • first language, including sign language;
  • preferred language, including sign language, manually coded English, cued speech, gesture, and speech;
  • level of speech reading competency;
  • other audiological/vestibular symptoms (e.g., tinnitus, balance impairment);
  • need for an interpreter; and
  • links to Deaf community (Grade C Evidence).

Keywords: Case History, Case History, Case History, Case History

"The individual's ability to use their aided hearing for functional listening in everyday home, school or work environments should be assessed" (p. 54) in addition to their aided ability to detect, discriminate, and identify environmental and linguistic sounds (Grade C Evidence).

Keywords: Educational/IFSP Considerations, Educational/IEP Considerations

When appropriate the assessment should include an evaluation of:

  • social and interaction skills including gesture use and understanding, facial expressions, social communication skills, and discourse skills (Grade C Evidence),
  • understanding and use of language in all relevant modalities including an analysis of use and understanding of semantics and grammar (Grade C Evidence),
  • aided and unaided auditory skills (Grade C Evidence),
  • speech production and intelligibility (Grade C Evidence), and
  • vocal characteristics including prosody, pitch, resonance, and range (Grade C Evidence).

Keywords: Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language, Hearing Loss, Hearing Loss

An assessment should include the child's ability to use their amplification for functional listening in everyday situations. It should also include the child's use of multi-modal communication (e.g., gesture, sign). Assessment of sign language competence will require collaboration with fluent sign users. The speech-language pathologist will need to consider the unique needs of children with hearing loss from multi-lingual backgrounds (Grade C Evidence).

Keywords: Auditory/Oral, Sign Language, Devices, Hearing Aids, Hearing Aids, Auditory-Oral, Sign Language, Communication Modalities, Communication Modalities, Communication/Speech-Language, Devices, Communication/Speech-Language

The clinician should evaluate speech reading abilities at the single word and connected discourse levels with consideration for visual and auditory-visual strategies (Grade C Evidence).

Keywords: Speech Reading, Speech Reading, Communication Modalities, Speech Reading, Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language

The clinician should also assess social and interaction skills across a range of contexts, including gesture, facial expression, social communicative behavior, and discourse skills in both spoken and sign languages. Compensatory communicative strategies should be observed and noted.

Keywords: Auditory/Oral, Sign Language, Auditory-Oral, Sign Language, Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language, Hearing Loss

The clinician should assess the individual's multi-modal receptive and expressive communication including gesture, spoken language, speech, sign language, and written language. The assessment of sign language competence will require close collaboration with fluent sign language users (Grade C Evidence).

Keywords: Auditory/Oral, Sign Language, Total Communication, Auditory-Oral, Sign Language, Total Communication, Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language

When appropriate the assessment should include an evaluation of preverbal communication skills including symbolic play, eye contact, turn-taking and independence in spontaneous interaction and communicative contexts (Grade B Evidence).

Keywords: Communication/Speech-Language, Communication/Speech-Language

Treatment

An assessment should include the child's ability to use their amplification for functional listening in everyday situations. It should also include the child's use of multi-modal communication (e.g., gesture, sign). Assessment of sign language competence will require collaboration with fluent sign users. The speech-language pathologist will need to consider the unique needs of children with hearing loss from multi-lingual backgrounds (Grade C Evidence).

Keywords: Auditory/Oral, Sign Language, Devices, Hearing Aids, Hearing Aids, Auditory-Oral, Sign Language, Communication Modalities, Communication Modalities, Communication/Speech-Language, Devices, Communication/Speech-Language

When appropriate to the child, management of hearing loss in children should include the following:

  • intervention to develop early communication skills (e.g., eye contact, initiation, turn-taking),
  • approaches to develop social and interaction skills (e.g., non-verbal communication, discourse skills, social communication skills, compensatory strategies for communicative deficits),
  • direct or indirect strategies to facilitate the development of receptive and expressive language skills,
  • environmental modifications to make language and communication more accessible,
  • auditory training,
  • direct treatment to improve the child's speech or sign intelligibility, and
  • speech reading (Grade C Evidence).

Keywords: Sign Language, Speech Reading, Auditory Training, Auditory Training, Environmental Modifications, Sign Language, Speech Reading, Communication Modalities, Aural Habilitation, Communication Modalities, Speech-Language Intervention, Aural Habilitation/Rehabilitation, Speech-Language Intervention

Consider direct therapy to improve sign intelligibility in conjunction with a competent sign language user (Grade B Evidence).

Keywords: Sign Language, Speech-Language Intervention, Sign Language, Communication Modalities, Communication Modalities, Speech-Language Intervention

Speech-reading may be a prerequisite for auditory training and "may facilitate recognition of lip shapes, anticipation and use of context from very basic lip patterns to single words to running speech" (Grade C Evidence; p. 59).

Keywords: Speech Reading, Speech-Language Intervention, Speech Reading, Communication Modalities, Communication Modalities, Speech-Language Intervention

Auditory training is an essential prerequisite to any speech production work for children for whom spoken language will be the primary mode of communication. Auditory training extends from closed-set activities to functional listening which may include auditory/speech-reading activities (Grade B Evidence). "Auditory training will form an essential part of the management of speech intelligibility for those deaf children for whom spoken language will be the primary mode of communication. This extends from closed-set activities to functional listening. Functional listening may include auditory/speech-reading activities. It is therefore a prerequisite to any speech production work" (Grade B Evidence; p. 59).

Keywords: Auditory Training, Aural (Re)Habilitation, Auditory Training, Speech-Language Intervention, Auditory Training, Aural Habilitation/Rehabilitation, Speech-Language Intervention, Hearing Loss

Direct and/or indirect approaches may be appropriate to:

  • develop non-verbal communication;
  • develop conversational and discourse skills;
  • develop the social rules of communication;
  • teach strategies used to compensate for linguistic or communicative difficulties; and
  • improve receptive and expressive aspects of spoken, signed, or written language (as appropriate) including semantic, grammatical and phonological competencies (Grade C Evidence).

Keywords: Compensatory Strategies, Aural (Re)Habilitation, Compensatory Strategies, Speech-Language Intervention, Aural Habilitation/Rehabilitation, Speech-Language Intervention, Hearing Loss

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Assessment

In addition to gathering information about medical history, the clinician should consider collecting the following case history information:

  • age at diagnosis, type, nature, and etiology of hearing loss;
  • age at intervention;
  • audiological test results;
  • type of amplification, age at fitting, and consistency of use (if applicable);
  • recommended hearing aid settings and use of environmental devices (if applicable);
  • first language, including sign language;
  • preferred language, including sign language, manually coded English, cued speech, gesture, and speech;
  • level of speech reading competency;
  • other audiological/vestibular symptoms (e.g., tinnitus, balance impairment);
  • need for an interpreter; and
  • links to Deaf community (Grade C Evidence).

Keywords: Case History, Case History, Case History, Case History

When appropriate the assessment should include an evaluation of preverbal communication skills including symbolic play, eye contact, turn-taking and independence in spontaneous interaction and communicative contexts (Grade B Evidence).

Keywords: Communication/Speech-Language, Communication/Speech-Language

Treatment

When appropriate to the child, management of hearing loss in children should include the following:

  • intervention to develop early communication skills (e.g., eye contact, initiation, turn-taking),
  • approaches to develop social and interaction skills (e.g., non-verbal communication, discourse skills, social communication skills, compensatory strategies for communicative deficits),
  • direct or indirect strategies to facilitate the development of receptive and expressive language skills,
  • environmental modifications to make language and communication more accessible,
  • auditory training,
  • direct treatment to improve the child's speech or sign intelligibility, and
  • speech reading (Grade C Evidence).

Keywords: Sign Language, Speech Reading, Auditory Training, Auditory Training, Environmental Modifications, Sign Language, Speech Reading, Communication Modalities, Aural Habilitation, Communication Modalities, Speech-Language Intervention, Aural Habilitation/Rehabilitation, Speech-Language Intervention

Go to Map

Assessment

In addition to gathering information about medical history, the clinician should consider collecting the following case history information:

  • age at diagnosis, type, nature, and etiology of hearing loss;
  • age at intervention;
  • audiological test results;
  • type of amplification, age at fitting, and consistency of use (if applicable);
  • recommended hearing aid settings and use of environmental devices (if applicable);
  • first language, including sign language;
  • preferred language, including sign language, manually coded English, cued speech, gesture, and speech;
  • level of speech reading competency;
  • other audiological/vestibular symptoms (e.g., tinnitus, balance impairment);
  • need for an interpreter; and
  • links to Deaf community (Grade C Evidence).

Keywords: Case History, Case History, Case History, Case History

"The individual's ability to use their aided hearing for functional listening in everyday home, school or work environments should be assessed" (p. 54) in addition to their aided ability to detect, discriminate, and identify environmental and linguistic sounds (Grade C Evidence).

Keywords: Educational/IFSP Considerations, Educational/IEP Considerations

When appropriate the assessment should include an evaluation of:

  • social and interaction skills including gesture use and understanding, facial expressions, social communication skills, and discourse skills (Grade C Evidence),
  • understanding and use of language in all relevant modalities including an analysis of use and understanding of semantics and grammar (Grade C Evidence),
  • aided and unaided auditory skills (Grade C Evidence),
  • speech production and intelligibility (Grade C Evidence), and
  • vocal characteristics including prosody, pitch, resonance, and range (Grade C Evidence).

Keywords: Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language, Hearing Loss, Hearing Loss

An assessment should include the child's ability to use their amplification for functional listening in everyday situations. It should also include the child's use of multi-modal communication (e.g., gesture, sign). Assessment of sign language competence will require collaboration with fluent sign users. The speech-language pathologist will need to consider the unique needs of children with hearing loss from multi-lingual backgrounds (Grade C Evidence).

Keywords: Auditory/Oral, Sign Language, Devices, Hearing Aids, Hearing Aids, Auditory-Oral, Sign Language, Communication Modalities, Communication Modalities, Communication/Speech-Language, Devices, Communication/Speech-Language

The clinician should evaluate speech reading abilities at the single word and connected discourse levels with consideration for visual and auditory-visual strategies (Grade C Evidence).

Keywords: Speech Reading, Speech Reading, Communication Modalities, Speech Reading, Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language

The clinician should also assess social and interaction skills across a range of contexts, including gesture, facial expression, social communicative behavior, and discourse skills in both spoken and sign languages. Compensatory communicative strategies should be observed and noted.

Keywords: Auditory/Oral, Sign Language, Auditory-Oral, Sign Language, Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language, Hearing Loss

The clinician should assess the individual's multi-modal receptive and expressive communication including gesture, spoken language, speech, sign language, and written language. The assessment of sign language competence will require close collaboration with fluent sign language users (Grade C Evidence).

Keywords: Auditory/Oral, Sign Language, Total Communication, Auditory-Oral, Sign Language, Total Communication, Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language

"Post-lingually deafened adults and some, but not all, school-aged deaf children may require assessment with closed-set speech perception materials" (Grade C Evidence; p. 56).

Keywords: Speech Perception, Speech Perception

Treatment

An assessment should include the child's ability to use their amplification for functional listening in everyday situations. It should also include the child's use of multi-modal communication (e.g., gesture, sign). Assessment of sign language competence will require collaboration with fluent sign users. The speech-language pathologist will need to consider the unique needs of children with hearing loss from multi-lingual backgrounds (Grade C Evidence).

Keywords: Auditory/Oral, Sign Language, Devices, Hearing Aids, Hearing Aids, Auditory-Oral, Sign Language, Communication Modalities, Communication Modalities, Communication/Speech-Language, Devices, Communication/Speech-Language

When appropriate, clinicians may provide advice on classroom management to facilitate access to the curriculum. This may involve:

  • modification of methods of presentation of information;
  • development of a range of tools to aid organization;
  • different methods of delivery; and/or
  • staff training (Grade B Evidence).

Keywords: Aural (Re)Habilitation, Compensatory Strategies, Counseling and Education, Environmental Modifications, Speech-Language Intervention, Educational/IEP Considerations

Clinicians should collaborate with others to adapt the physical, social, sensory, and linguistic environment to enhance language and communication accessibility (Grade C Evidence).

Keywords: Aural (Re)Habilitation, Environmental Modifications, Speech-Language Intervention, Educational/IEP Considerations, Environmental Modifications, Aural Rehabilitation

Consider direct therapy to improve sign intelligibility in conjunction with a competent sign language user (Grade B Evidence).

Keywords: Sign Language, Speech-Language Intervention, Sign Language, Communication Modalities, Communication Modalities, Speech-Language Intervention

Speech-reading may be a prerequisite for auditory training and "may facilitate recognition of lip shapes, anticipation and use of context from very basic lip patterns to single words to running speech" (Grade C Evidence; p. 59).

Keywords: Speech Reading, Speech-Language Intervention, Speech Reading, Communication Modalities, Communication Modalities, Speech-Language Intervention

Auditory training is an essential prerequisite to any speech production work for children for whom spoken language will be the primary mode of communication. Auditory training extends from closed-set activities to functional listening which may include auditory/speech-reading activities (Grade B Evidence). "Auditory training will form an essential part of the management of speech intelligibility for those deaf children for whom spoken language will be the primary mode of communication. This extends from closed-set activities to functional listening. Functional listening may include auditory/speech-reading activities. It is therefore a prerequisite to any speech production work" (Grade B Evidence; p. 59).

Keywords: Auditory Training, Aural (Re)Habilitation, Auditory Training, Speech-Language Intervention, Auditory Training, Aural Habilitation/Rehabilitation, Speech-Language Intervention, Hearing Loss

Direct and/or indirect approaches may be appropriate to:

  • develop non-verbal communication;
  • develop conversational and discourse skills;
  • develop the social rules of communication;
  • teach strategies used to compensate for linguistic or communicative difficulties; and
  • improve receptive and expressive aspects of spoken, signed, or written language (as appropriate) including semantic, grammatical and phonological competencies (Grade C Evidence).

Keywords: Compensatory Strategies, Aural (Re)Habilitation, Compensatory Strategies, Speech-Language Intervention, Aural Habilitation/Rehabilitation, Speech-Language Intervention, Hearing Loss

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Assessment

When appropriate the assessment should include an evaluation of:

  • social and interaction skills including gesture use and understanding, facial expressions, social communication skills, and discourse skills (Grade C Evidence),
  • understanding and use of language in all relevant modalities including an analysis of use and understanding of semantics and grammar (Grade C Evidence),
  • aided and unaided auditory skills (Grade C Evidence),
  • speech production and intelligibility (Grade C Evidence), and
  • vocal characteristics including prosody, pitch, resonance, and range (Grade C Evidence).

Keywords: Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language, Hearing Loss, Hearing Loss

The clinician should also assess social and interaction skills across a range of contexts, including gesture, facial expression, social communicative behavior, and discourse skills in both spoken and sign languages. Compensatory communicative strategies should be observed and noted.

Keywords: Auditory/Oral, Sign Language, Auditory-Oral, Sign Language, Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language, Hearing Loss

Treatment

Direct and/or indirect approaches may be appropriate to:

  • develop non-verbal communication;
  • develop conversational and discourse skills;
  • develop the social rules of communication;
  • teach strategies used to compensate for linguistic or communicative difficulties; and
  • improve receptive and expressive aspects of spoken, signed, or written language (as appropriate) including semantic, grammatical and phonological competencies (Grade C Evidence).

Keywords: Compensatory Strategies, Aural (Re)Habilitation, Compensatory Strategies, Speech-Language Intervention, Aural Habilitation/Rehabilitation, Speech-Language Intervention, Hearing Loss

"The [speech-language pathologist] SLP will explain the relationship between hearing and communication, and will be available for discussion and support. Intervention should seek to facilitate the development of early communication skills, particularly appropriate eye contact, initiation, communicative intent and turn-taking skills" (Grade C Evidence; p. 58).

Keywords: Provider, Hearing Loss

Service Delivery

"The [speech-language pathologist] SLP will explain the relationship between hearing and communication, and will be available for discussion and support. Intervention should seek to facilitate the development of early communication skills, particularly appropriate eye contact, initiation, communicative intent and turn-taking skills" (Grade C Evidence; p. 58).

Keywords: Provider, Hearing Loss

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Assessment

"A formal assessment and/or skilled observation of the ... phonetic and phonological repertoire [of a child who is deaf or has a hearing loss] may be appropriate, and a profile of their speech ... intelligibility in a range of communicative contexts should be drawn up. This should include both their use of segmental and supra-segmental features in spoken language" (pp. 56-57).

Keywords: Hearing Loss

When appropriate the assessment should include an evaluation of:

  • social and interaction skills including gesture use and understanding, facial expressions, social communication skills, and discourse skills (Grade C Evidence),
  • understanding and use of language in all relevant modalities including an analysis of use and understanding of semantics and grammar (Grade C Evidence),
  • aided and unaided auditory skills (Grade C Evidence),
  • speech production and intelligibility (Grade C Evidence), and
  • vocal characteristics including prosody, pitch, resonance, and range (Grade C Evidence).

Keywords: Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language, Hearing Loss, Hearing Loss

The clinician should formally evaluate the individual's phonetic and phonological repertoire in a range of communicative contexts as appropriate. A profile of speech and/or sign intelligibility should be created considering both segmental and non-segmental language features (Grade C Evidence).

Keywords: Hearing Loss

Treatment

"Direct therapy may be needed to improve the ... speech ... intelligibility [of a child who is deaf or has a hearing loss].... Speech intelligibility therapy might take place at the phonological and/or phonetic level and may include both segmental and supra-segmental features. Therapy at this level should be preceded by the development of speech perception skills" (Grade B Evidence; p. 59).

Keywords: Timing (e.g. Pre- and Post-Op), Target Selection, Hearing Loss

Auditory training is an essential prerequisite to any speech production work for children for whom spoken language will be the primary mode of communication. Auditory training extends from closed-set activities to functional listening which may include auditory/speech-reading activities (Grade B Evidence). "Auditory training will form an essential part of the management of speech intelligibility for those deaf children for whom spoken language will be the primary mode of communication. This extends from closed-set activities to functional listening. Functional listening may include auditory/speech-reading activities. It is therefore a prerequisite to any speech production work" (Grade B Evidence; p. 59).

Keywords: Auditory Training, Aural (Re)Habilitation, Auditory Training, Speech-Language Intervention, Auditory Training, Aural Habilitation/Rehabilitation, Speech-Language Intervention, Hearing Loss

Service Delivery

"Direct therapy may be needed to improve the ... speech ... intelligibility [of a child who is deaf or has a hearing loss].... Speech intelligibility therapy might take place at the phonological and/or phonetic level and may include both segmental and supra-segmental features. Therapy at this level should be preceded by the development of speech perception skills" (Grade B Evidence; p. 59).

Keywords: Timing (e.g. Pre- and Post-Op), Target Selection, Hearing Loss

Go to Map

Assessment

When appropriate the assessment should include an evaluation of:

  • social and interaction skills including gesture use and understanding, facial expressions, social communication skills, and discourse skills (Grade C Evidence),
  • understanding and use of language in all relevant modalities including an analysis of use and understanding of semantics and grammar (Grade C Evidence),
  • aided and unaided auditory skills (Grade C Evidence),
  • speech production and intelligibility (Grade C Evidence), and
  • vocal characteristics including prosody, pitch, resonance, and range (Grade C Evidence).

Keywords: Communication Modalities, Communication Modalities, Communication/Speech-Language, Communication/Speech-Language, Hearing Loss, Hearing Loss

The clinician should assess the individual's functional voice, including quality, pitch, range, resonance, and volume in several communicative contexts (Grade C Evidence).

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