Before It’s Too Late: Catching Language and Listening Challenges Upstream

TLDR: We are failing children with hearing challenges, and most people do not even realize it.

Imagine a d/Deaf child raised without sign language, relying only on listening and lipreading. Years later, they finally get an ASL interpreter, but no one has actually taught them ASL. When they still struggle, the school decides that “sign language doesn’t work.” It sounds absurd, but this happens all the time.

We do the same thing with cochlear implants, hearing aids, and yes, auditory training. When a tool fails, we blame the tool instead of asking whether it was ever set up to succeed in the first place.

It was difficult at first for me to see the limitations of my own tool, the low-gain programming of hearing aids, which is a method that uses hearing aids to slightly amplify sound for children with normal hearing thresholds so speech is clearer without over-amplifying. I am a pioneer in this field and have seen incredible results, so it was hard to imagine anything could do more for a child than providing clearer signals. What I forgot was the size of the gap some children have from years of not hearing well.

When interventions like ASL or a cochlear implant happen too late, they are downstream interventions in the river of language development. If they had been introduced near the snowpack, the earliest source of language learning, when the child was very young, the fallout would have been far less.

Think about Genie, the feral child who had some language until about age 2 and then none at all until she was found at age 12. By then, it was too late to fully teach her language. In the same way, children with hearing loss who had received ASL with well-fit powerful hearing aids or possibly bilateral cochlear implants with consistent language access, whether visual through ASL or Cued Speech or through large amounts of auditory training, much earlier in life would have been in far better shape.

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What Happens in the Brain

This is one of the challenges we see with auditory processing disorder. These children are hard of hearing in the brain, often because of a history of auditory deprivation, meaning their brain received an unclear or inconsistent signal in the early years.

During the brain’s critical period for language development, roughly birth to age 5, the auditory cortex needs a strong, clear signal to develop its ability to decode sound. If it does not get that signal, the brain may permanently struggle to process speech, even if hearing tests later appear “normal.”

Many of the clients that speech therapists work with today have articulation, language, and reading problems rooted in this early deprivation.

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Classification Matters

These children should be classified as Deaf and Hard of Hearing, not Other Health Impairment or Specific Language Impairment. Their challenges are not behavioral and not purely language-based, they stem from incomplete access to the speech signal. Without improving that access, every other intervention is compromised. If the language gap is large, visual language must be provided alongside hearing aids, auditory training, or both.

Too often, we skip this step and treat the problem as behavioral or misclassify it as a language impairment without looking at the underlying auditory access. By the time reading, language, and behavioral issues show up downstream, we have missed the upstream cause.

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Why the Field is Divided

Some speech pathologists categorize auditory processing disorder as a language disorder rather than a signal-based access problem. There are professionals who doubt the diagnosis entirely due to poor early test research and inconsistent treatment outcomes. Others prefer oral-only approaches because of cultural preferences for oralism or because visual language resources are difficult to access.

These differing perspectives lead to inconsistent identification, support, and intervention for the children who need it most.

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Systemic Barriers

Access to timely intervention is not equal. Families in rural areas may have no local audiologist skilled in pediatric hearing technology. Many families cannot afford hearing aids due to poor insurance coverage, and insurance coverage for low-gain hearing aids or FM systems is rare for children who have normal hearing thresholds. Compared to children with diagnosed hearing loss, approval rates are much lower, and Medicaid almost never covers this use. Skilled ASL instructors or Cued Speech specialists are often concentrated in certain regions, leaving others without options.

DHH resources are already very limited, and in some cases there is territoriality and gatekeeping within the field. These supports are sometimes withheld from children who are perceived as having “normal” hearing, even when they have a history of auditory deprivation and clear functional listening challenges. This exclusion not only limits access to services but also keeps these children out of DHH environments such as deaf schools or DHH classrooms, where they could benefit from visual language and cultural support. As a result, they miss opportunities to be immersed in settings designed for accessible communication and language development.

There are also only a few audiologists who make low-gain hearing aids with FM systems their primary specialty. Even when families are interested in this combined approach, they may have to travel long distances, navigate long waitlists, or work with providers who do not have deep experience with this programming. Many schools, speech pathologists, physicians, and other professionals have never heard of this off-label application.

The technology itself has been around for years, but using it specifically for children with normal hearing thresholds and auditory processing or language access needs is relatively new. This application only began to emerge around 2013, with foundational research first appearing in 2008, and there has been almost no large-scale research since.

The lack of research is partly due to the heterogeneous nature of the children who benefit from it, which makes it difficult to form large, uniform study groups. The cost of the equipment also makes research challenging, and randomized trials are nearly impossible because parents are understandably unwilling to let their children go without help for the sake of a control group.

These disparities and access barriers mean some children miss the critical period for language entirely.

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Choosing and Combining Tools

I do not care which tool is used. We can teach visual languages like ASL, use Cued Speech, provide auditory training, or fit low-gain hearing aids. I like hearing aids because they offer immediate access with less effort than learning a new language, though they carry some stigma. Visual languages require full family participation. Cued Speech supports literacy and home languages but takes time. Auditory training can take three to six months to show results. Good cognitive training, while incorporating portions of auditory training as well as emphasis on attention, focus, and resilience, takes time, scheduling, and money.

The key is to fix the signal as early as possible. Fixing the signal alone, however, is often not enough if we are already far downstream. In those cases, we must add interventions to make up for lost time.

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A Change in Perspective

A parent in my APD Facebook group recently shared that her child made two years of sustained gains from computerized auditory training programs designed to improve listening in noise and working memory. That story challenged my thinking. I had spoken with Lalsa Perepa, Dr. Courtney Stone, other audiologists, and patients who had benefited. I could not keep dismissing it.

Often auditory training is like a scalpel, precise but narrow, and the skills may not generalize. But in the right hands, it can make a real difference. Hearing aids can be like scaffolding, broad but incomplete. Together, they can close gaps that neither can close alone.

I recently apologized for having never supported auditory training. Now I apologize for my black-and-white thinking, because when a child’s future is at stake, “enough” should never be the goal.

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Dayenu and the Call to Action

Dayenu, which means “it would have been enough”, is a beautiful song from Passover about the Jews escaping Egypt. I love its message about gratitude, pausing to appreciate what you have, seeing the good that already exists, and not always chasing the next thing. But when it comes to your child, their future, and their potential, “enough” should never be the goal.

It is time for professionals, parents, and policymakers to bridge the gaps in thinking, research, and access. No child should be denied the tools and environments they need during their critical years for language and learning.