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How Language Difficulties Lead to School Failure Proposal

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Updated: Jul 13th, 2021

Literature Review

Hearing Loss

Hearing impairment, or hearing loss, is an inability to distinguish and perceive sounds. A person with a disability may not hear at all or may have little hearing (Cole & Flexer, 2019). It can impact both ears and may lead to challenges at work, school, and other areas of human activity (Bigler et al., 2019). Hearing loss can be categorized by its severity – the louder the sound should be for a person to be able to hear, the more critical is the degree of the hearing impairment (Calcus, Tuomainen, Campos, Rosen, & Halliday, 2019). An individual that does not hear at all is called a deaf person (Cole & Flexer, 2019). Loudness is only one aspect – some rare types of hearing loss impact the human’s ability to discriminate speech (Bigler et al., 2019). For instance, people with auditory neuropathy can hear sounds well but have trouble when understanding human speech (Moser & Star, 2016). Public health measures may significantly contribute to the prevention of hearing loss.


There are multiple causes of hearing loss, including aging, noise, genetics, physical trauma, medications, or perinatal problems (Cole & Flexer, 2019). The cause is also connected with the etiology of the hearing impairment – the loss can be sensorineural (SNHL), conductive (CHL), or mixed (MHL) (Calcus et al., 2019). Children at school age acquire hearing impairment mostly due to middle ear disease and cerumen impaction (Mulwafu, Kuper, & Ensink, 2016). In some cases, it is challenging to determine what exactly led to the disability (Bigler et al., 2019). Earwax may also lead to hearing impairment if enough earwax is accumulated to block the canal and pose a hindrance to the conduction of sounds (Cole & Flexer, 2019). The list of possible causes is long and growing as science advances to provide with more discoveries.


Generally, when a person has to consistently ask to speak louder, it is a sign that this individual may have a hearing impairment (Cole & Flexer, 2019). However, there are also additional symptoms that may not be as evident (Curhan & Curhan, 2016). For instance, people with hearing loss may have trouble distinguishing consonants or may perceive certain sounds as muffled (Curhan & Curhan, 2016). While adults immediately seek doctor’s assistance when they experience any of the mentioned symptoms, children, especially infants, have fewer opportunities to provide feedback (Cole & Flexer, 2019). Children with hearing impairment express a limited ability to speak, frequently lose attention, and are frustrated when there is a lot of background noise (Cole & Flexer, 2019).

Areas Affected in the Brain

There is no extensive evidence about how exactly hearing loss impacts the brain. However, the current research suggests that part of the brain that is responsible for processing signals from the ears may reorganize itself if a person has a hearing impairment (Cole & Flexer, 2019). As the brain cells get reassigned to other functions, individuals may experience a decline in their cognitive abilities (Glick & Sharma, 2017). The authors call this phenomenon the cross-modal cortical reorganization (Glick& Sharma, 2017). This notion can explain why age-related hearing loss is strongly linked with dementia (Cole & Flexer, 2019). Hearing loss negatively impacts children’s mismatch negativity (MMN) to sounds as they grow older (Calcus et al., 2019). By the time they are adolescents, the majority of hearing-impaired show age-inappropriate MMNs (Calcus et al., 2019). Early detection does not guarantee that the hearing impairment will adequately be treated (Cole & Flexer, 2019). However, it does provide opportunities to mitigate some of the adverse effects of hearing loss (Cole & Flexer, 2019).

Language and Self-esteem Outcomes

Children with hearing impairments can experience delays in language development (Cole & Flexer, 2019). According to Tomblin et al. (2015), younger individuals with no consistent access to hearing aids perform much weaker in terms of language levels compared to children with normal hearing. This deterioration, in turn, adversely impacts the children’s learning abilities (Cole & Flexer, 2019). Because of worse school performance, hearing-impaired children may experience low self-esteem (Cole & Flexer, 2019). Individuals with normal hearing are more socially mature and have better communication skills (Warner-Czyz, Loy, Evans, Wetsel, & Tobey, 2015). In front of such peers, children with hearing loss are at risk of having issues with confidence.


The efficacy of interventions varies, and no universal intervention exists because hearing loss has many different effects that should be treated separately (Cole & Flexer, 2019). For instance, Self-instructional Parent Program and Filial therapy can be applied to solve behavioral problems in children that arise because of hearing impairment (Bigler et al., 2019). However, only the latter was proved to be effective to some extent, while the parent program failed at generating any impact (Bigler et al., 2019). Hearing aid wear can be used to expose the children to their auditory environments (Cole & Flexer, 2019). However, such equipment is expensive, and not every family can afford it (Cole & Flexer, 2019). For mitigating the adverse effects of hearing loss on language development, there are Early Intervention services provided by health institutions (Cole & Flexer, 2019).


Areas Affected in the Brain

Individuals with ADHD have smaller brain sizes compared to people with no ADHD (Friedman & Rapoport, 2015). Notably, the disorder leads to volume reductions in the prefrontal cortex, parietal-temporal regions, basal ganglia, and cerebellum (Friedman & Rapoport, 2015). ADHD also leads to degradation in the person’s cognitive abilities (Fuermaier et al., 2015). However, these deteriorations are not ubiquitous, and people with ADHD have different cognitive profiles (Fuermaier et al., 2015). The nature of the disease is complicated, and more research is needed to determine the exact mechanisms that cause cognitive degradation (Friedman & Rapoport, 2015).

Language and Self-esteem Outcomes

Children with ADHD relatively have no challenges with the use of language structure (Hawkins, Gathercole, Astle, Holmes, & CALM Team, 2016). However, pragmatic language difficulties that are associated with ADHD can be an obstacle to building effective communication (Hawkins et al., 2016). A high number of research papers throughout history consistently indicated that children with ADHD have pragmatic language problems (Korrel, Mueller, Silk, Anderson, & Sciberras, 2017). There is also research evidence that ADHD leads to poor self-esteem outcomes in the long run (Harpin, Mazzone, Raynaud, Kahle, & Hodgkins, 2016). Impaired social function is one of the consequences of untreated ADHD (Harpin et al., 2016). However, available treatment models, both pharmacological and non-pharmacological, can lead to significantly more favorable results (Hawkins et al., 2016).


As with hearing loss, many interventions target a specific aspect of ADHD. For instance, the placebo response yielded from electroencephalography-neurofeedback seems to be useful for the treatment of some ADHD symptoms (Thibault, Veissière, Olson, & Raz, 2018). However, language difficulties need other interventions, and different types of language impairments may require various forms of therapy (Hawkins et al., 2016). To target ADHD as a whole, behavioral therapy, lessons on stress management and relaxation, and behavioral coaching may be used (Thibault et al., 2018).

Proposed Strategies

Explicit Direct Instruction

Explicit direct instruction (EDI) is among the proposed strategies that may be used to assist hearing-impaired children and young individuals with ADHD. EDI is a framework of teaching practices that is based on the latest research conducted by leading pedagogues (Hollingsworth & Ybarra, 2017). EDI is comprised of strategically planned lessons that explicitly provide new information until the concept is taught to mastery (Hollingsworth & Ybarra, 2017). Each lesson, according to EDI, should contain eight elements to achieve successful outcomes (Hollingsworth & Ybarra, 2017). These components are learning objectives, activation of prior knowledge, concept development, skill development, guided practice, relevance, closure, and periodic reviews (Hollingsworth & Ybarra, 2017). During the lessons, instructors should use engagement norms to ensure that children are busy all the time and are engaged in the learning process (Hollingsworth & Ybarra, 2017).

Current evidence is limited to the assessment of the efficacy of direct instruction. Because EDI can be considered as an enhanced derivative of direct instruction, EDI should perform better (Hollingsworth & Ybarra, 2017). There is evidence that direct instruction is suitable for teaching language skills to hearing-impaired children. In the research conducted by Lund and Douglas (2016), all participating children were able to learn a high number of new vocabulary words under direct instruction. It can be proposed that EDI will be capable of leading to even better results.

Follow-in Labeling

Follow-in labeling is how parents teach their infants – providing cues to children, pointing at objects and naming them, and leading children’s eye gaze to a target object ((Lund & Douglas, 2016). Usually, children successfully establish references between visual cues provided by their parents and labels (Lund & Douglas, 2016). Visual cues may include any action – for instance, looking at an object, pointing at the object, touching it, or shaking it (Lund & Douglas, 2016). Children with normal hearing consistently use these actions to set word-referent pairings.

Follow-in labeling is found to be an effective method of teaching new words to hearing-impaired children (Lund & Douglas, 2016). Although the results do not supersede the effects provided by direct instruction, children performed favorably under this mode of learning (Lund & Douglas, 2016). While 9 out of 9 children learned the designated amount of words under direct instruction, 8 out of 9 learned almost the same number of words under follow-in labeling (Lund & Douglas, 2016).

Incidental Exposure

Incidental learning can be contrasted to EDI because learning happens with no intention and set goals. Therefore, the patterns by which we learn every day are a mix of incidental and intentional learning (Hollingsworth & Ybarra, 2017). While incidental exposure happens consistently to children with normal hearing, individuals with hearing impairments and ADHD are less prone to such a learning model because of the inability to perceive all sounds and the absence of attention (Lund & Douglas, 2016). Therefore, the disorders should be diagnosed as early as possible to provide the children with necessary hearing aid wear and equipment so that they may engage in incidental learning (Cole & Flexer, 2019). This strategy includes but is not limited to using microphones in learning environments, using hearing technology at least 10 hours a day, auditory-based family therapy, and family support (Cole & Flexer, 2019).

Lund and Douglas (2016) determined that, among direct instruction, follow-in labeling, and incidental exposure, the latter is the worst method because children did not learn well under this strategy. However, it should be noted that the researchers did not use any technical equipment that is necessary for hearing-impaired children (Lund & Douglas, 2016). Therefore, with all the hearing aid wear in place, children may be able to score better when taught using the incidental exposure model. The researchers believe that combining all three strategies to deliver information to hearing-impaired children will create more learning opportunities, thus enhancing the results (Lund & Douglas, 2016). Research should be conducted to determine how children with ADHD perform under these instruction models.


Bigler, D., Burke, K., Laureano, N., Alfonso, K., Jacobs, J., & Bush, M. L. (2019). Assessment and treatment of behavioral disorders in children with hearing loss: A systematic review. Otolaryngology–Head and Neck Surgery, 160(1), 36-48.

Calcus, A., Tuomainen, O., Campos, A., Rosen, S., & Halliday, L. F. (2019). eLife, 8. Web.

Cole, E. B., & Flexer, C. (2019). Children with hearing loss: Developing listening and talking, birth to six. San Diego, CA: Plural Publishing.

Curhan, G., & Curhan, S. (2016). Epidemiology of hearing impairment. In G. Popelka, B. Moore, R. Fay, & A. Popper (Eds.), Hearing aids (pp. 21-58). Basel, Switzerland: Springer.

Friedman, L. A., & Rapoport, J. L. (2015). Brain development in ADHD. Current Opinion in Neurobiology, 30(1), 106-111.

Fuermaier, A., Tucha, L., Koerts, J., Aschenbrenner, S., Kaunzinger, I., Hauser, J.,… & Tucha, O. (2015). Cognitive impairment in adult ADHD – perspective matters! Neuropsychology, 29(1), 45.

Glick, H., & Sharma, A. (2017). Cross-modal plasticity in developmental and age-related hearing loss: Clinical implications. Hearing Research, 343(1), 191-201.

Harpin, V., Mazzone, L., Raynaud, J. P., Kahle, J., & Hodgkins, P. (2016). Long-term outcomes of ADHD: A systematic review of self-esteem and social function. Journal of Attention Disorders, 20(4), 295-305.

Hawkins, E., Gathercole, S., Astle, D., Holmes, J., & CALM Team. (2016). Language problems and ADHD symptoms: How specific are the links? Brain Sciences, 6(4), 1-17.

Hollingsworth, J. R., & Ybarra, S. E. (2017). Explicit direct instruction (EDI): The power of the well-crafted, well-taught lesson. Thousand Oaks, CA: Corwin Press.

Korrel, H., Mueller, K. L., Silk, T., Anderson, V., & Sciberras, E. (2017). Research review: Language problems in children with attention‐deficit hyperactivity disorder – a systematic meta‐analytic review. Journal of Child Psychology and Psychiatry, 58(6), 640-654.

Lund, E., & Douglas, W. M. (2016). Teaching vocabulary to preschool children with hearing loss. Exceptional Children, 83(1), 26-41.

Moser, T., & Starr, A. (2016). Auditory neuropathy – neural and synaptic mechanisms. Nature Reviews Neurology, 12(3), 135-149.

Mulwafu, W., Kuper, H., & Ensink, R. J. H. (2016). Prevalence and causes of hearing impairment in Africa. Tropical Medicine & International Health, 21(2), 158-165.

Thibault, R. T., Veissière, S., Olson, J. A., & Raz, A. (2018). Treating ADHD with suggestion: Neurofeedback and placebo therapeutics. Journal of Attention Disorders, 22(8), 707-711.

Tomblin, J. B., Harrison, M., Ambrose, S. E., Walker, E. A., Oleson, J. J., & Moeller, M. P. (2015). Language outcomes in young children with mild to severe hearing loss. Ear and Hearing, 36(1), 76S-91S.

Warner-Czyz, A. D., Loy, B. A., Evans, C., Wetsel, A., & Tobey, E. A. (2015). Self-esteem in children and adolescents with hearing loss. Trends in Hearing, 19, 1-12.

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