Providing Individualized Services for DHH Children, Given Their Large Individual Differences

The issue


Infants with normal hearing are able to hear the full range of speech sounds at birth. When born to parents who communicate with speech, they are surrounded by spoken language for 9 to 12 months before they utter their first words.

Over 95% of infants born with permanent hearing loss have parents who communicate with spoken language. There is continuing controversy about which language or communication mode (e.g., sign language, spoken English, bilingual education, Total Communication, Signed Exact English) is “most effective” for children who are deaf or hard of hearing (DHH). For some parents and professionals, there are clearly “right” and “wrong” choices. Relevant concerns include social-emotional health, language and cognitive development, and academic performance.

When parents learn that their baby may not have full access to the language of the home, they must explore their communication choices, define communication goals for their child, and advocate for the resources required to make language accessible. They must also make decisions about educational services and periodically reassess their decisions to adapt to their child’s strengths and needs as they become apparent.

What we know

Identification of hearing loss and enrollment in appropriate early intervention (EI) programs, regardless of language/communication approach, by 6 months of age optimize language outcomes for DHH children. Based upon this evidence, the goals of Early Hearing Detection and Intervention (EHDI) are to perform hearing screening for all infants by 1 month of age (universal newborn hearing screening or UNHS), identify hearing status of infants with permanent hearing loss by 3 months of age, and enroll them in appropriate EI programs by 6 months.

Acquisition of language is central to social-emotional health, cognitive development, and academic performance. UNHS is critical to identify permanent hearing loss as early as possible. EI services for DHH infants and toddlers should be focused on communication and language development. The specific communication approach is not as important as consistent exposure to accessible language. In the United States, children over 3 years of age are eligible to receive services from their school programs through development of an Individualized Education Program (IEP). The level of services provided varies by state and school district.

Every effort should be made to make language accessible. For example if the family chooses to communicate with ASL, parents and other family members must become fluent in ASL.  The child’s vision should be assessed and monitored. Ideally, the family would seek out the Deaf community to provide language and cultural models.

If the family chooses to use Total Communication or spoken English, every effort should be made to help the child hear speech. The acoustic environment should be optimized with the reduction of background noise and reverberation and appropriate technologies.

Families want to make the best choices for their children. Yet it may be difficult for some families to become fluent in another language and use it consistently in their daily routines. Conversely, deaf children may learn better when information is presented visually.

There are a number of factors that contribute to a child’s ability to learn language, including consistency of language models, access to the language presented, and innate language learning ability. There are even more factors, most notably executive functions, which contribute to their cognitive development and social emotional health. Families may choose one approach and find that their children are thriving.  Others may notice that their children are not making expected progress with a given approach. Families and providers must maintain an open mind to accommodate the large individual differences among children who are deaf or hard of hearing.

What we don’t know

Parents make decisions about communication approach when their child is only a few months of age, often seeking guidance from professionals.  Professionals, who usually have normal hearing themselves, frequently make recommendations based upon the child’s hearing status. However, it is difficult to predict what language and educational approach will be most suitable for a child based solely upon an audiogram.


Families must be informed of and encouraged to learn about all communication options for their children with hearing loss.  Because most hearing parents communicate with speech, they must learn about the differences and relationships between speech, language, and cognition. They must also understand the central role of effective communication in their children’s social-emotional development. Families should be empowered to reassess their choices and consider further evaluation and redirection if necessary.

Posted on October 1, 2014 by
Kathleen C.Y. Sie
Director, Childhood Communication Center
Seattle Children’s Hospital
kathleen.sie {at}

Further reading