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Speech and Language Issue or a Hearing Problem?

August 1st, 2009 by | Tags: , , , , , , , , , | 5 Comments »

Sometimes it is difficult to tell whether or not a child with a hearing loss is presenting with a true speech and/or language disorder, or if the problems in their speech and language skills are due to hearing loss alone.  For some children, you think, “Wow.  This kiddo probably would have had speech/language issues even without his hearing loss!”  For example, some speech and language problems, like fluency disorders (i.e. stuttering), have a strong genetic component.  But other times, you think, “Does this child really have speech and language problems, or is she just delayed because of inadequate access to hearing?”  These two theories require very different therapeutic approaches.  For a child with a true speech and language issue, like apraxia, that is unrelated to his or her deafness, a more traditional “speech therapy” approach may be in order.  For the latter group of children (in my opinion, the majority of children with HL), the goal should be to give the child more access to sound, and more listening and spoken language training, to allow them to develop these skills — a developmental, acoustic approach, not a remedial, visual plan.  But where do you draw the line?  How do you decide the “cause” of these invisible, ever-changing delays or disorders, especially when so many children with hearing loss are not “just deaf” and often have a multitude of complicating factors?

Well, the literature and common sense offer some starting points for how we can consider these issues.

First, as always, it’s very important to remember that children SAY what they HEAR.  If the child is not receiving access to sound, his or her speech is going to be impacted because of it.  If you have typical hearing, think about when you get off of a plane or have a cold and your ears are stopped up.  Do you feel self-conscious or worry that your voice is nasally, too loud, or too soft?  I know I do!  That’s because we constantly monitor our own speech through the auditory feedback loop — you hear what you say, and make adjustments accordingly when you hear that you’ve pronounced something wrong, or at the wrong volume, etc.  For deaf children whose parents have chosen listening and spoken language, the goal is that they will be able to do the same.  For them, as for people with typical hearing, the best possible access to sound is crucial for self-monitoring.

For children with hearing aids, no matter how good and well-programmed they are, the high frequencies that distinguish some speech sounds may still be inaudible.  If a child is suspected of having a “language disorder” because he omits the plural “-s” (cats) or possessive “-’s” (Matt’s) or third-person singular (walks), could it be that he just cannot hear the high-frequency components of the /s/ sound and so he’s not language disordered, he’s just saying what he hears?  Same would go for /f/, /?/ (“sh” as in shoe), or /?/ (“th” as in thumb).

Ling (2002) lists the following “Examples of Speech Patterns stemming from Inadequate Perception that Were Often Confused with Phonologic Process”

  • Substitution (switching sounds, putting an incorrect sound in the place of the correct sound)
  • De-affrication (not saying affricate sounds, like saying “dump” for “jump,” where “j” is the affricate sound)
  • Omission or stopping of fricatives (for the fricative “f” as in fun, the child either omits “-un” or adds a stop sound “pun”)
  • Weak syllable reduction (leaving out unstressed syllables — “nana” for “banana”)
  • Cluster reduction (leaving out parts of a cluster, or “blend” — like “tar” for “star”)
  • Stridency deletion (“noisy” sounds like “ch, j, sh, z” are either left out or replaced, so “chair” becomes “air” or “tair”)
  • Liquid Simplification (liquids are /r/ and /l/, child would say “w” for /r/, so “wake” for “rake”, and/or “y” for “l”, so “yook” for “look”)

So what does that mean in English, please?  Basically, what Ling is saying is that these patterns, which would commonly be treated by a general SLP in a very, “put your tongue like this and lips like this, let’s look in the mirror and see how it looks”-type approach, in children with hearing loss, we should try to optimize HEARING first, and help the children attain more normal, natural speech and language patterns through AUDITION alone, before introducing more traditional visual/tactile methods.  (For children with typical hearing, the general SLP’s approach may be entirely appropriate.  These children have the benefit of an intact auditory system, and really may need some visual supports.  For a child who has experienced auditory deprivation, however, we must try to build their auditory brain first and foremost, to establish the neural connections that will benefit them for the rest of their lives!)

So, moral of the story:  sometimes, kiddos with hearing loss really DO have some other speech, language, or oral motor issues that must be dealt with in ways outside of the listening and spoken language approach.  First and foremost, however, we must ensure that children have optimal auditory access and lots and lots of auditory learning opportunities to see if some of the issues will clear up based on increased listening and spoken language/developmentally-based  treatment, not a visual/remedial approach.  As always, consult a Listening and Spoken Language Specialist, TOD, or SLP with experience working with deaf children who use a listening and spoken language approach, to learn more information and create a treatment plan specifically tailored to the needs, strengths, and weaknesses of your child.

Written by

Elizabeth Rosenzweig MS CCC-SLP LSLS Cert. AVT is a Listening and Spoken Language Specialist Certified Auditory Verbal Therapist. She provides auditory verbal therapy, aural rehabilitation, IEP advocacy, consultation, and LSLS mentoring for clients around the world via teletherapy. You can learn more about Elizabeth's services on her Website or Facebook.


August 1, 2009 at 10:42 pm

For many years I’ve maintained that wherever there’s a speech impediment, there’s a hearing loss lurking in the shadows.

Address the hearing problem, and watch the speech problems clear up with therapy.

Let’s reverse the issue when it comes to children: Why would you NOT address the hearing loss as soon as it’s discovered?


August 2, 2009 at 12:47 pm

DAN: I agree. Most SLPs/Schools/Clinics, at least here in the US, will do a hearing screen as part of the evaluation for any child referred for speech-language services (or make sure they have a current audiogram in their records sent from another professional). Everyone should! It’s just common sense and part of a comprehensive evaluation — the legally mandated school screenings don’t catch everything, and it never hurts to double-check!

August 3, 2009 at 12:17 pm

Great post, Elizabeth! One of the biggest clues my parents noticed that made them get my hearing tested (at the ripe ol’ age of three and a half) was that my speech was getting worse and worse. Even with my hearing aids, “house” was “how” “mix” was “mi” and “knives” was “kni”. It took me years to be able to pronounce my name right, and it wasn’t until I got my CI’s that I could finally say “My birthday is on September sixth” (rather than eptember ick, or some other weird variation)

And people wondered why I insisted on them guessing my birthday, or just holding up six fingers :P

Ross Adams, M.S., CCC-SLP

September 26, 2009 at 1:28 pm

The author of the original post writes that a phonological processing disorder would be “commonly . . . treated by a general SLP in a very, ‘put your tongue like this and lips like this, let’s look in the mirror and see how it looks’-type approach” which is completely inaccurate. A phonological disorder is a disorder of the speech sound system and is treated by retraining the rule-system which the child has internalized incorrectly (or incompletely) using an auditory approach. The clinician facilitates the child’s ability to hear the difference between the child’s own (error) production and the clinician’s standard production and successively approximate that standard production over time, using their own ear as the guide. By contrast, “look at my mouth, look in the mirror” sorts of cues are reserved for situations when speech-motor involvement is suspected and/or a more ARTICULATION approach is being undertaken. Motor learning is by nature more visual and, therefore, requires heightened visual cues (i.e., you learn to dance by watching/doing, not listening), so an articulation approach would involved the sorts of cues the author mentioned. A phonological approach involving deaffrication, stridency deletion, etc. would not.

dwi yanti

November 8, 2012 at 7:36 am

So nice n informative article ;)I’m a speech therapist from Indonesia.Who have hearing impairment children ,7 year old(unilateral cochlear implant).Thanks to share information about it.I can’t wait next article ;)
Best regards