Wednesday, April 25, 2007

Young People Part 2 Language Development

Following my brief look at the changing pattern of family life in Britain, I'd like to turn my attention to children's language development, since the two are inextricably linked.

Human babies are amazing creatures: given normal hearing and average cognitive ability, they progress from 'mewling and puking' to being masters of their mother tongue(s) in less than four years. After infancy, new language is learned in a different way, which most of us find quite difficult. Whether we subscribe to the Chomsky or the Bruner theory of first language acquisition, or think, as I do, that the truth lies in a combination of the two, there is no questioning the fact that all over the world, in primitive tribes and civilised societies, babies acquire speech and language in a seemingly effortless way.

So why is delayed language development among children of school-entry age the major concern of those involved in Early Years education in Britain today? Communication difficulties affect social and educational progress and are frequently associated with behavioural difficulties in children of secondary school age. The usual suspects of television, working mothers or simply being a boy have been blamed and in Australia the answer has been discovered in middle ear infections. In fact all of these issues can be seen to be inter-related.

I spent the last twenty years advising parents and teachers on language development in children with impaired hearing and the twenty years prior to that teaching deaf children. Only 1 per 1000 babies is born with severe sensorineural deafness but as many as 1 in 4 children suffer some degree of temporary hearing loss due to otitis media with effusion (OME), commonly known as 'glue ear.' While the children with permanent deafness were my main concern, I was involved in the assessment of children with glue ear and in advising their parents and teachers on how to minimise the impact of the hearing loss on their educational development. Between 1990 and 2006, the number of referrals I received to assess children with conductive hearing loss caused by glue ear increased from an average of 30 per year to 30 per month. Working with audiologists and paediatricians to discover the reasons for this increase, I concluded that the actual incidence of episodes of glue ear had not increased but the impact on the development of speech and language was greater than in the past.

Having to devise a new way of working in order to cope with the numbers of children being referred from 67 schools scattered over a large rural area, I produced information leaflets for parents, presentations for health and education professionals and a guide on language development for teachers in Early Years settings. Within months, I was overwhelmed by requests to attend meetings and address conferences; sadly, this was not a tribute to my wit and charm but an indication of the level of concern among a range of professionals dealing with ever-rising numbers of children with poor speech and language skills.

Otitis media with effusion, OME or glue ear, is usually a minor medical condition and doctors are right to resist pressure to rush to surgical solutions. It is a condition that requires good management rather than intervention. It is an educational rather than a medical issue. The behavioural and cognitive sequelae of OME were established many years ago by the Dunedin Project and confirmed in many later studies. What has changed in the 33 years since the Dunedin study began is the scale of the problem. As I said earlier, the incidence has not increased but the impact has.

Language development and hearing

(For any outraged scientists who might be reading, this is the Audiology for Dummies version)

This illustration gives an indication of the relative pitch (frequency measured in Hertz) and intensity ('loudness' measured in decibels) of common sounds.

You can see the all-important 'speech banana' which shows the range of speech sounds in the average adult voice.

The white section indicates what would be considered the 'normal' range of hearing responses, with the heavy line representing a typical audiogram for a young child i.e. a similar response to all frequencies at minimal levels.

Responses mainly in the yellow section would indicate a mild hearing loss, the green section a moderate loss and so on. A typical audiogram of a 4 year old with glue ear would show a fairly straight line around 40-45 dBHL. The child would have difficulty in hearing any of the sounds above the line showing his 'threshold of hearing'. (Surgical intervention - myringotomy and insertion of ventilation tubes, 'grommets' - would normally be considered appropriate if the hearing loss was greater than this and persisted for more than 6 months)

The speech banana shows that vowel sounds and the voiced consonants b, m, n, l, g, ng, r, and j are clustered together in the lower frequency and the higher intensity range of the banana. Therefore they are the easiest sounds to hear and those are the first sounds that babies produce in their babbling. It is no mere chance that parents are called dada and mama! You will also see that f, th and s are the highest pitched and the softest sounds; these are the last speech sounds to appear in a child's repertoire and cause difficulties for many children.

In order to learn spoken language, an infant needs to hear clearly articulated speech at a level at least 15 decibels above his threshold of hearing. Imagine you enter a room where the radio is on at a barely perceptible level; if the programme is a discussion of your favourite topic, you will recognise some of the words and begin to make sense of what you hear. On the other hand, if it is in a foreign language or full of technical jargon from a subject you know nothing about, you will pay no attention because it will be a meaningless background noise; if you want to understand, you will turn up the volume. So it is with young children acquiring speech, a very mild hearing loss during the critical period for speech acquisition will disrupt that development.

The impact of modern lifestyles on language acquisition

This is an oversimplified comparison between what I will call 'traditional' childrearing methods and modern lifestyles, most real people are somewhere in the middle:

Babies are prone to brief episodes of very mild hearing loss; their eustachian tubes are narrow and easily blocked by mucus during a cold or when teething. In traditional situations, babies were carried around for most of the time, close to the mother, grandmother or older sibling and the proximity to the speaker compensated for the mild hearing loss. Most modern babies spend a lot of time in carry cots or bouncers at a distance from adult voices so their speech is not heard clearly.

Traditionally, infants spent most of their time in an intimate family setting, hearing and interacting with the same person or small group of people who would adapt their speech to evoke responses from the baby - what is termed 'motherese'. While not correcting the infant's utterances, the mother would automatically model the correct language, we call this the 'maternal reflective' input to language development. Infants in day care, whether nurseries or with childminders, do not get this intimate, individual nurturing treatment.

Modern homes are filled with sound from washing machines and vacuum cleaners to day long television or music in the background. Nurseries are filled with the noise of many children talking, singing and playing. Infants cannot discriminate new speech sounds from background noise, even when their hearing is normal. Glue ear usually has no symptoms other than mild hearing loss and this can easily go undetected because the child responds to the loud noises around it.

Traditionally, children learned a lot of the features of language incidentally e.g. anticipation, turn-taking and rhyming through shared activities like peek-a-boo and nursery rhymes. During my home visits in the last twenty years, I found 7 out of 10 mothers did not know any language games or nursery rhymes and I had to teach them some to use with their toddlers. While Sesame Street, Teletubbies and other children's programmes may be entertaining and can be useful for reinforcing already acquired skills, they are no substitute for child-carer activities.

Another startling change I noticed in modern homes was the lack of a family dining table. Children learn a great deal about how to behave and how to converse during family meals. Adults and older siblings are the role models for language and behaviour and this feature of development is being lost because of poorly designed modern starter homes and TV dinners on trays. It has been interesting to watch the recent spate of reality programmes on television, dealing with 'problem children' or 'problem families'. In every case, the turning point in the programme was when the family started to eat at least one meal a day together at a table.

Managing change

We don't want to go back to the days when women stayed at home, keeping house with washtub, mangle and broom. But we need to look at what else was thrown out when the new labour-saving appliances were introduced. The most obvious change is that women have time to develop interests outside of the home, and some have no choice but to work to pay for all those new appliances. I don't want to pile guilt on mothers who choose or are forced to put their babies into daycare, but I want them to appreciate what has been lost and look at ways of compensating for that loss.

In terms of language acquisition, the main loss has been intimacy. It is in a close, quiet, physical relationship with a carer that babies learn to understand and use spoken language. If possible, therefore, a nanny or childminder with a very small number of children will be a better choice than a nursery with lots of children and many different adults.

Children, especially boys, are prone to develop glue ear between the ages of 18 and 24 months and again around 5 years of age. The symptoms may not be startlingly obvious, look out for lack of response to quiet sounds, and a decrease in vocalisation in younger infants, and for older children turning up the volume on the television, misunderstanding or apparently ignoring instructions, lack of attention or daydreaming, lots of 'what' or pardon?' Often children with glue ear are mistakenly labelled unco-operative or slow learners.

Temporary episodes of hearing loss can be managed by letting everyone who deals with the child know about it. Always get the child's attention before giving an instruction or information e.g. 'Johnny, it's time for bed. Go and brush your teeth.' is more likely to get the desired response than 'Off you go to bed now and remember to brush your teeth, Johnny.' When nursery teachers adopt this way of speaking to all the children in their care, they find a noticeable improvement in behaviour; in fact, it is an improvement in communication. Get close to the child when speaking, to compensate for the reduced hearing level. Check that information has been received correctly. Make allowance for the fact that a child with even a mild hearing loss has to concentrate harder and so will tire easily.

Those children who are arriving at school at age 5 with delayed language need lots of activities that they missed out on in early infancy to encourage language development. There are lots of books available (including mine!) with ideas for parents, carers and teachers to help them do what our grandparents did as a matter of course.


  1. Brilliant essay. It illustrates the immense causal complexity of life.

  2. (By the way, you can change the date of posts to get them to the top of the page via Posting Options underneath the main box of the post).

  3. Thank you, Brit. I'm relieved that you don't think I am being anti-progress. I think there have been many wonderful and beneficial changes for ordinary people, but that we should always be aware of the consequences of change and address them sensibly.

  4. Thanks for the latest tip. I've managed to change the date on the post!

  5. This is fascinating. I had never heard of "glue ear" or "Otitis media with effusion", despite having been a child and having raised two children. A little Googling reveals that glue ear is what we in the States call a middle ear infection, which we mostly treat by ignoring it. If ignoring it doesn't work, a brief course of antibiotics is prescribed. I've never heard of anyone suggesting that a child with a middle ear infection go see a speech therapist.

    On the other hand, apparently there's been what Lancet calls an "epidemic" of surgical responses to glue ear in the UK. I saw a tantalizing yet ambiguous suggestion that this has to do with what NHS will pay for.

  6. David:
    Welcome! I hope you enjoyed (are maybe are still enjoying?) your trip to England.

    Yes, minor surgical treatment for 'glue ear' is the most common operation for children at present. My post explains why I think this is unnecessary and maybe wrong.

  7. I have been thinking about David's comment and it appears to support my view on glue ear needing management rather than treatment, except in severe or persistent cases. The reports that I have read of American studies all state that there is no link between glue ear and language delay - all the negative reports come from UK, Australia, New Zealand and South Africa. Could this have anything to do with child-rearing methods, I wonder?

  8. MoNix:

    Thanks. We're back home now, but had a great time in London. Our only problem was that we didn't really pack correctly for consistently sunny and hot weather.

    The high point, of course, was meeting Anna (and Brit, I suppose).

    I took our kids for their annual physicals yesterday, and was amused to see that our pediatricians are now screening all of their patients for depression. That might explain why they don't have time to waste on middle ear infections.

  9. monix:

    Wow and wow. That's what I call an education. Thank you very much.

    On the theory that every good post deserves a derivative conservative whine, I must say I understand your frustration that so many modern parents won't admit to the downside of the new liberated order or invest time in trying to compensate for it. In addition to looking to pills and experts to solve it, I suspect you have encountered exculpatory reactions that more or less approximate the following:

    A)Oh sure, blame Mom. Why can't Dad read and talk to them more? I'm not supporting the patriarchy;

    B)Little Johnny's slight and temporary hearing problem is more than compensated for by his wildly superior socialization skills;

    C)Of course I want to do it, but he just refuses to read or listen. How can I be so mean as to impose my values on him?;

    and my personal favourite:

    D) It was much worse in the 14th century.

  10. Peter:

    I agree with you on the excuses issue, I could fill a book! It's all part of not taking responsibility. Perhaps it's because the thirty-somethings have grown up believing that someone (or Google) has the answer to every problem, they are not encouraged to rely on their own instincts or judgement. Then, when it goes wrong, they look for someone to blame, after all that's what the politicians do.

    You hadn't heard of global warming?

    I'm glad you met lovely Anna and I hope the boy listened well. I'm looking forward to hearing some moderated opinions on Scripture.

    I am greatly relieved to have retired before screening for depression catches on here. I have read that pet dogs are being prescribed prozac, so why not infants? I got out in time!

  11. How does the depression screening work?

  12. There's a questionnaire that boils down to asking teenagers if they ever feel all alone and like nobody understands them.

    The only question I remember with any specificity was "Do you have trouble falling asleep, sleeping through the night or staying awake?" The choices were Never, Sometimes or Often. Ben marked down "Sometimes" because he tends to fall asleep in the car on long trips.

  13. Have you ever seen the AA questionnaire for alcoholism? If you restrict yourself to one sherry at Christmas, they allow you may be ok but they still urge you to monitor things closely.

  14. I don't wish to be hurtful, Peter, but aren't questionnaires the brainchild of lawyers to obfuscate the truth? I was once a prosecution witness in court and the defence lawyer would only allow me to give yes/no answers, so the true story wasn't revealed. I thought the same when I did jury service, I would have liked to ask more questions in order to understand better.

  15. Lawyers may have much to answer for, but I don't think that is one. It is the hyper-rationalists from the social sciences and MBA programmes you should blame for thinking the essence of every experience in this vale of tears can be captured by ticking off twenty boxes. Your problem was with the rules of evidence, which are of much more ancient provenance and are based on a suspicion absolute truth is largely inaccessible as it is always filtered through fallible human perception.

  16. I have a great respect for the law, Peter. I can get carried away by my own flippancy on occasions.

  17. monix, I have been arguing with your son for quite some time now. If I were sensitive to criticism from the blogosphere, I would have jumped off a bridge years ago. Fire away, o' flippant one.

  18. Yes, all our best efforts at abuse have not been able to drive Peter away. You're stuck with him, Monix!

    Wonderful essay. I second David's reaction. I've never heard of Glue Ear either.

    A better test of depression wouldn't be lost sleep, but too much sleep. As one who has experienced depression and takes medication for it, I have mixed feelings on the treatment of young people for depression. It is possible to overdiagnose and overprescribe for depression in the young, but there is the opposite danger of underdiagnosing as well. The "kids are allright, leave 'em alone" camp may be correct in most instances of dealing with youthful angst, but you can't generalize to all kids. Knowing how antidepressants have helped me as an adult, I think they would have benefitted me immensely as a teenager as well.

    For those of you who missed it, here's my take on the depression deniers.

  19. Thank you for the kind words on my essay, Duck. Thanks too for the link to your post on depression, I've just finished reading it and all the complex arguments that followed. I won't be drawn into the happiness versus suffering debate, which I think is quite distinct from the proper medical treatment of depression. However, I see a connection with the comments on the use of Ritalin and my views on parenting. In our schools, Ritalin is not given to children who used to be labelled 'slow-learners' (they are now labelled as 'dyslexic') but to boys with behavioural problems. It keeps them quiet but it doesn't seem to sort out the behaviour.

  20. Excellent informative and well written essay.

    Ear problems don't always show up as hearing loss. Our son by age two (he's 48 now) had one ear infection after the other. The medications prescribed by our pediatrician were ineffective, so we bundled him up and took him to the free clinic at Manhattan Eye and Ear hospital.

    Best thing we could have done. He was examined by one of the best doctors on the staff and because we really didn't qualify for the free clinic, we made an appointment to see him at his office. In a matter of days, a completely successful myringotomy was performed. The result: our son was never bothered with an ear infection again.

    I find it amusing that people who put their kids in daycare or employ nannies from birth up, can't figure out why their kids don't speak well. Their hearing is fine, they are merely learning to speak from the caregivers many of whom have decidedly poor language skills. At a parent-teacher meeting, I was complimented on my kid's spoken language, good grammar, etc. and asked how I managed it. Duh? I stayed home until my youngest was sixteen. That's how.

    There are so many other good points in your post, it would take too much space to comment on them all, but I have to say, right on, about trying to make boyish exuberance and high spirits an aberration that needs to be medicated.

  21. Thank you, erp. I don't know if women in the states are under the same pressure as here to get back to work as quickly as possible after the birth of their babies. I know many women feel they have to in order to maintain their standard of living, but our government has put a great deal of pressure on women too, so that it is regarded as a kind of social failure to be a stay-at-home mum.
    I was lucky that we were able to afford for me to do without an income for ten years. I kept my career going through volunteer work and was able to pick up again when I felt the children were well on their way.

  22. m, I believe the pressure to have lessened. Young women today have no memory of being on less than equal footing with men, so they're more likely to make decisions to suit themselves.

    When I talk about the ways things were when I was young, they simple can't believe it. For instance when we bought our first house, I had a good, high paying job, but we couldn't get a mortgage because only the man's salary could be considered!

  23. It's interesting that you say that the pressure has lessened, erp. Maybe something different is happening? I can't find a link, but I read a report recently that one third of graduate women in UK will not have any children - from choice. As women are , as you say, equal with men in the professions and commerce, perhaps they won't want to put their careers on hold to have babies. Unless we restore some value and dignity to motherhood, my generation might never become grandmothers!

  24. Do you think society can or even should mount an ad campaign urging women to have children?

    My forty-something niece, in the wake of two failed marriages, went to Guatemala and paid a king's ransom to adopt a sweet little girl. Now she's finding that being a single mom (how I hate that word), even with a live-in nanny, requires a great deal of her time, so she palms off the child to friends who take her on outings to the zoo, for holiday dinners, etc. because she has no patience for "family stuff."

    I dread what the next years will bring if the child doesn't measure up to the high standards she expects of herself and others.

  25. erp:
    My optimistic nature tells me that sooner or later society sorts itself out. I think the rapid rate of change in recent years has left many people floundering, and there are inevitable casualties. But I'm hopeful that people are waking up to the problems and, while they may be throwing money and crackpot ideas at them for now, eventually wisdom will emerge.

    It's not a new situation really, is it? Look at what happened after the selfish, dissolute Georgian age in England - we got the Victorian era! It may not be in our lifetime, but I think a balance will be established eventually.


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