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8. PRE-SCHOOL ISSUES: INFORMED CHOICE AND ASSESSMENTS

8.1. BACKGROUND

It is generally agreed that early childhood is a critical period for language development, and parents of deaf children report that choice about language and communication is one of the most important decisions they have to make ( DfES, 2006:27). Deaf infants, like hearing infants are 'little linguists' (Brennan, 1999). SCoD has position papers on preschool as well as on school education, both of which stress the importance of linguistic access: 'The key to early support should be seen as linguistic access' ( SCoD, 2005).

The advent of Universal Newborn Hearing Screening ( UNHS) means that professionals are in contact with families when babies are as young as a few weeks old. At this age, 'knowledge about the deaf child's strengths and weaknesses as a language learner is simply too limited to allow an exclusive choice for either signed or spoken language' (Knoors, 2007). The implication of this statement is that, therefore, it would be beneficial to provide a rich environment of both sign and spoken languages after diagnosis.

Also, a series of recent developments have increased the potential for more deaf children to develop language at the same rate as their hearing peers:

- early diagnosis following the roll-out of UNHS (both spoken and signed language development);
- developments in cochlear implantation - more sophisticated devices and increased possibilities for implanting at earlier ages (spoken language development);
- resources released following the recognition of BSL as a minority language (signed language development).

However, recommending that both signed and spoken languages are pro-actively offered to families of newly diagnosed deaf babies remains controversial; some of the main arguments can be summarised as follows:

On one hand, there are arguments that:

• Early diagnosis and early fitting of hearing aids/early cochlear implantation enables greater access to spoken language than ever before. Therefore audition should be maximised, without a need to introduce BSL, to give the best chance for the development of age-appropriate spoken language.
• Over 90% of deaf babies are born to hearing parents and therefore the main language at home for the vast majority is English, or, in a minority of cases, another spoken language.
• There are not the resources available to provide a rich environment in BSL - both in terms of hearing professionals with advanced skills and in terms of Deaf early years professionals who are native BSL users.
• English is the majority language of the country and of the curriculum, and so deaf children need to fully focus on spoken English from the start, to enable them to cope as well as they can.
• Using a sign language and identifying with other deaf people creates separation from majority culture. It is necessary to relate to hearing people in adult life at work and in accessing services, without needing to have recourse to language service professionals such as BSL/English interpreters.
• A concern that using sign language will be detrimental to the development of spoken language and to achievement of educational potential.
• Educational achievements of cochlear implanted children are generally likely to be greater than those of profoundly deaf children who do not have implants.

On the other hand, there are arguments that:

• Sign language can be naturally acquired by deaf babies at the same rate as hearing children acquire spoken language. It is not detrimental, and can be beneficial to, the development of spoken or written English (including early diagnosed children with cochlear implants).
• Deaf infants can develop a signed language even where the sign level of parents/carers starts relatively low.
• Some deaf children have greater aptitudes for sign language than for spoken language; for these children, delay in exposure to BSL will be specifically detrimental. However, it is not possible to identify these children in early infancy.
• Developing two or more languages from infancy is beneficial rather than detrimental, generally.
• Viewing BSL as a positive alternative rather than a last resort will empower a child to later make their own linguistic access choices from a position of strength. Delay in learning BSL will disadvantage this option.
• Limiting access to BSL will restrict later chances of benefiting from a natural identification with both deaf and hearing cultures, and increase likelihood of cultural isolation.
• There is new opportunity to provide BSL environments, following enhanced funding for BSL Tutor training and for production of BSL assessment and development resources.

There is UK-wide evidence that underpinning conceptualisations of deafness itself (linguistic deficit or linguistic difference) can affect not only the range of choices available to families, but the attitude with which they are presented (Young et al, 2006). Furthermore, the medical environment surrounding early diagnosis and amplification can lead to an immediate expectation of 'cure' - of 'catching it in time' - which encourages a deficit rather than a linguistic perspective (op cit).

As has already been demonstrated, language policies of local authority services vary among local authorities and staff in individual services have developed different positions in response to the above arguments. Thus, even where BSL is offered as a linguistic choice, it could be offered in a discouraging rather than encouraging way and/or the resources for supporting the family in developing the language may be so limited that it is not a realistic possibility.

Underpinning this is a positioning of BSL within a communication support context, rather than a linguistic framework, in key documentation relating to language diversity within education (Scottish Executive, 2006:13). An explicit listing of BSL as part of the 'rich diversity of language' within Scotland would provide a lead in reframing it as a language rather than as a means of remedying a deficit.

NDCS, in collaboration with Manchester University, recently produced guidelines on the provision of 'informed choice' to parents of deaf children, including language and communication choices ( DfES, 2006:27).

In the light of these developments and dilemmas, this section aims to explore briefly what is known about linguistic choices and assessments offered to deaf preschool children and their families in Scotland.

8.2. LANGUAGES USED WITH PRE-SCHOOL DEAF CHILDREN IN SCOTLAND ( ADPS, 2001)

ADPS has data on languages used with preschool children at home and among a range of professionals working with the child. For most years, the data is unexplored. In 2001, out of 211 survey responses (88% response rate), ToDs reported that the main home language of 94% of the preschool deaf children was English. 4% of families used BSL and the others used equal levels of Urdu and Punjabi.

Records were completed for 179 deaf preschool children on the languages used by parents and professionals with the child. Table 8 shows that all of the children were exposed to English and 37% (67) of them were exposed to BSL to some extent. Data are also available on the break-down of extent of usage of individual languages/modes by each type of professional.

Chart 8 Languages/language modes used by parents and professionals with deaf preschool children in 2001 (=179)

8.3. UNHS IN SCOTLAND

All Scottish Health Boards have been screening in the newborn period since 2005. However, a recent clinical audit of NHS Audiology Services in Scotland found that, while ' UNHS is a successful national programme', there were regional variations in service and a need for standardisation of protocols, monitoring arrangements, information and communication systems (Davis et al, 2007:36).

Crosshouse cochlear implant service reports geographical variation in the number of infant referrals coming from Health Boards, suggesting variation in referral procedures.

Although the audiology audit made reference to early intervention, SaLT services and Family Support Services, audition was not placed in the context of a spectrum of linguistic choices and permutations.

8.4. EARLY INTERVENTION

There is currently no national framework for early intervention. At the time of writing, NDCS is currently campaigning for this to be addressed.

Where babies are identified through UNHS, they are likely to receive hearing aids at around 4 months. Concerns are expressed in the audiology audit report that amplification should be offered earlier than this where there is very early confirmation of deafness (Davis et al, 2007:46).

To DS (who may be Educational Audiologists in some areas) are most likely to be the key professionals working with parents right from the time of diagnosis. Therefore ToDs are key advisors to parents about language choices and development.

Speech and Language Therapists ( SaLTs) are also key professionals, and the audiology audit reports that all 'they often formed an underpinning role in the early intervention services' (op cit: 39). The experience of one informant suggested that it is possible for there to be a degree of tension between ToDs and SaLTs, as to who is appointed as key worker.

It was reported that at least one service has a Deaf Support worker as well as Educational Audiologist who work together with families of deaf babies and toddlers. There is not a consistent provision of professional consultancy in age-appropriate BSL linguistic issues.

8.5. TRAINING, QUALIFICATIONS AND RESOURCES FOR EARLY LINGUISTIC INTERVENTION

Visiting deaf education/ HI services have recently needed to boost training in the language development of newborn babies; such early stages of development were not previously part of the training for professionals. At least one person in each local authority visiting service is responsible for early intervention.

Informants reported that most services use resources from the DCFS Early Support Pack Monitoring Protocol ( DCFS, 2006). The pack covers detail on stages in linguistic development. Most comprehensive detail is provided on spoken English; BSL is included, but to a lesser extent.

There is only one accredited university programme which focuses on early years and deafness, based at Oxford Brookes University but available as distance learning. It is apparently common for Scottish local authorities to fund ToDs to undertake the programme. The programme addresses spoken language development only and does not include any information on early sign language development.

In 2003, ADPS data showed that only 5 out of the 28 Scottish services which provided primary intervention for families of newly diagnosed children employed teaching staff with advanced levels of BSL fluency. As noted, a small number of services also had a Deaf native BSL-user.

8.6. EARLY COCHLEAR IMPLANTATION

The Scottish cochlear implantation programme is based at Crosshouse hospital in Kilmarnock, and staff at the centre assess babies and children from all over the country. Cochlear implantation is possible at increasingly earlier ages; babies from some areas are less than one year old when assessed.

Referrals for assessments come direct from medical consultants (and, occasionally, GPs); ToDs and SaLTs are encouraged to be involved. 'Entry stage' for eligibility is bilateral severe-to-profound sensorineural loss, profound at high frequencies (2-4Kh), where the child is receiving limited benefit from hearing aids. Most parents who come for assessment state that they would like their child to have an implant and most who are assessed fall within the entry stage criteria.

The Crosshouse team work with all services, which means collaborating with staff who work within a range of language approach policies, some of which include BSL or SSE to varying degrees (see Section 3 and Appendix 1). The implant centre emphasises spoken language development and views the introduction of BSL as not needed where a baby is diagnosed neo-natally and referred for implantation in early years. Depending on a range of factors, some families already use spoken language only. Where a child has used signing prior to implantation, the centre expects to see a (sometimes gradual) change in emphasis towards an oral/aural approach post implant, as it is felt that this will give the best chance of developing age-appropriate spoken language. Some of these children do continue to favour signing after implantation; it is understood by the centre that they already had well-established sign skills prior to implant, but whether or not they have had formal BSL assessments is dependent on local capacity.

The aforementioned audiology audit contains a section on cochlear implantation. The section reports concerns expressed by the implant centre in relation to variable language approaches in local services - stating that some local authority services have 'a fixed policy on "mode of communication"', which is detrimental to the development of spoken language and that parents are often disallowed choice (Davis et al, 2007:39). Denial of choice is a matter of concern. While concerns have already been raised in this report about geographical variations in linguistic choice, evidence has pointed to the lack of availability of adequately resourced sign bilingual approaches rather than to a lack of resources for spoken language development, per se (see also Section 3 and Appendix 1). Therefore there appears to be a need for further exploration of the ways in which 'informed choice' is interpreted and implemented among services.

Further exploration and clarification would be helpful, but the situation may, to some extent at least, exemplify the fact that, for various reasons, people hold opposing views among the arguments set out in 8.1., above. When there is a plea for 'unbiased advice', what is meant by 'unbiased' is not always clear (eg Davis et al, 20007:46). The way that deafness is conceptualised and the fear that developing sign language will be detrimental to the development of spoken language may well underpin a tendency to define choice as an 'either spoken language or sign language' scenario. It certainly can be said that there are ongoing challenges in providing rich environments in both languages. It is of interest that the Ear Foundation has developed training on working with implanted children in sign bilingual settings. The Scottish Sensory Centre hosted a training day in January 2008.

It appears that there is a pressing need to take stock of what is known, in open and honest debate, in order to make the most of unprecedented opportunities for deaf children's linguistic and social development from diagnosis onwards - and for their access to education.

8.7. LINGUISTIC ASSESSMENTS ( ADPS, 2001)

There is ADPS data on linguistic assessments used with deaf preschool children during the period 2000/2005. Much of the data are unexplored, but Table 9 shows a summary of type of assessments used in 2001. It shows that most assessments were informal and that most linguistic assessments related to spoken English. Detail is also available on the names of the formal assessments carried out and on which professionals administered each assessment.

Table 8 Types of assessment done by services with deaf preschool children in Scotland: 2001 (=179)

According to informants, most services are now likely to use assessments from the DCSF Monitoring Protocol ( DCSF, 2006). Individual heads of service report that they adapt materials from the pack and devise informal assessments using, for example, video analysis. Interviewees also reported that other formal and informal assessments are used with older preschool children

8.7.1. SPOKEN LANGUAGE ASSESSMENTS ( ADPS, 2004/2005)

ADPS data shows that a wide range of assessments were used across Scotland between 2000 and 2005. As with the 2001 data in table 9, most recent unpublished data (2004/2005) shows a combination of informal and formal assessments, varying between services. Most common formal assessments reported were Reynell Developmental Language Scale; BPVS; Tait Video Analysis; Derbyshire Language Scheme and CELFUK. It would be interesting to know how the patterns have changed since the introduction of UNHS and the Monitoring Protocol mentioned above.

As already noted, there is little data on the extent of demonstrable expertise among professionals in the administration of spoken language assessments and follow-on development programmes. It is expected that SaLTs provide expertise in this area in addition to ToDs.

The Crosshouse cochlear implant team use spoken language assessments, which include both preverbal and verbal skills. Assessments are completed every 3 months of the first year and then at 18 months, 2 years, 3 years, 4 years and 5 years.

8.7.2. BSL ASSESSMENTS (SCOPING STUDY SURVEY, 2007)

The Deafness, Cognition and Language Research Centre ( DCAL) produce the only formal assessments available. They are also working on standardisation of the MacArthur Communicative Development Inventory in BSL. Correspondence with DCAL indicated that few professionals in Scotland are able to administer the BSL tests:

Assessment in BSL Production

Only 2 people in Scotland are currently trained to use the BSL Production Test (out of 60 people trained throughout the UK), although a training course is due to run via SSC in January 2008. Test administrators must have at least Level 2 BSL and have been on training course.

Assessment in BSL Reception

Eight BSL Receptive Skills Tests, aimed at children aged 3-11 years, have been sold in Scotland since 1999, when the test was published, out of several hundred sold throughout the UK. There are no training requirements for this test.

SQA are currently considering future provision of a PDA in BSL language development of preschool children.

8.8. RECOMMENDATIONS

• The preschool period is particularly important for language development, both signed and spoken. However, few services provide rich environments in both, and it is not universally accepted that both are needed.
  Huge strides have been made in the provision of services to facilitate early development of spoken language, including significant technological advances and accredited postgraduate training for professionals, and yet concerns have been expressed that some services do not provide sufficiently rich spoken language environments. Meanwhile there is evidence of low capacity in BSL skills and in provision of BSL assessments and resources among visiting services, despite evidence of benefits in developing both languages.
  There is a need to address evidence about BSL, in the contexts of standpoints based on the arguments as set out in 8.1. It is suggested that open and honest debate is needed, about the implications of local authority variations in language approach perspectives and in resources relating to fully informed linguistic choices.
• In particular, further research and discussion is needed on strategies to maximise conditions for developing both languages where deafness is diagnosed early, especially where a child receives a cochlear implant in early years.
• There is a need for Health Boards to address concerns about geographical variation in the provision of UNHS and early intervention services, as outlined in the recent clinical audit of audiology services (Davis et al, 2007).
• There is a need for more availability of BSL assessments, and more trained staff to administer them.
• It would be beneficial if a Scottish version of the Early Support Pack Monitoring Protocol could be developed and implemented within a national framework of provision. The development of a specialist PDA and the involvement of professional BSL consultants would enhance the linguistic balance of such a framework.

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