และการพูดของเด็กหูหนวกไทยในโครงการฟื้นฟูสมรรถภาพเด็ก หูพิการก่อนวัยเรียน กฤษณา เลิศสุขประเสริฐ , นิตยา เกษมโกสินทร์ , วิชิต ชีวเรืองโรจน์ , ลลิดา เกษมสุวรรณ ภูมิหลัง : การฟื้นฟูสมรรถภาพการฟังและการพูดของเด็กหูหนวก จะช่วยให้เด็กรับรู้เสียง และสื่อความหมายด้วย การพูด การศึกษาเป็นจํานวนมากได้ยืนยันถึงก

Background: An auditory-oral approach can help deaf children achieve success in oral communication. Many studies confirm that deaf children with access to sound through high-powered and appropriate hearing aids at the youngest age possible have the capability to acquire communication skills similar to their hearing peers. Objective: Evaluate the listening and speaking progress made by 27 Thai hearing-impaired children who attended a preschool aural rehabilitation program, which was established at Audiology and Speech clinic. After hearing aids fitting, deaf children were enrolled to the preschool aural rehabilitation program after receiving their parents consent. Material and Method: Hearing impaired children were divided into groups of 4-6 children with approximately the same level of performance. The listening and speaking performance at the initial period were recorded. Each group participated in the 3-hour-program once a week, included auditory training, conversation (maternal reflexive method), and speech stimulation. The improvements and problems of each child were recorded at the end of session. Listening and speaking performance evaluation were recorded at six months intervals. Results: There were 12 boys and 15 girls. The average hearing loss in the better ear was 104 dBHL, range from 83-117 dBHL, SD = 8.33. The mean age of enrollment was 2 years and 10 months. The majority gradually developed listening skills and speaking ability. There was no relationship between age of enrollment and the listening and speaking ability (p > 0.05). However, listening skills had positive relationship with length of speech (r = 0.685), number of spoken vocabulary (r = 0.665), and speech character (r = 0.598); p < 0.01. Conclusion: Auditory training is an important task to develop listening skills and improve length of speech, speaking vocabulary, and speech character. Other benefits from the aural rehabilitation program included monitoring the auditory progression after hearing aid fitting, parents meeting, and promotion a better quality of life by enabling hearing impaired children to participate in hearing society.

It is well known that many deaf children can develop their listening skills and spoken language by the use of amplifications.Most deaf children have some residual hearing, even a minimal amount of residual hearing, if stimulated, could lead to the development of spontaneous speech and oral communication (1) .In order to achieve this, deaf children must be identified earlier, fitted with appropriate hearing aids that are properly monitored and maintained.It is also essential to have a consistent and well-formed training program to support the children's current and changing needs (2) .With an auditory-oral approach, deaf children are trained how to use their residual hearing so that they access to spoken language, which is called auditory training (3) .Additionally, there is also focus on speech reading and contextual cues to give deaf children better understanding and use spoken language.If deaf children were trained orally, they will do well in life and permit earlier adjustment to a world in which speech is the chief means of communication (4) .
In Thailand, the educational system for hearing impaired children was formerly based on degree of hearing loss.If it exceeded 90 dBHL, deaf children were referred to deaf schools to study total communication, which mostly focus on signs, thus J Med Assoc Thai 2010; 93 (4): 474-80 Full text.e-Journal: http://www.mat.or.th/journal inhibiting the opportunity to learn listening, speaking and participate in the hearing society.At present, hearing loss is easily diagnosed soon after birth (5)(6)(7) with updated audiological technology.After proper medical evaluation and appropriate hearing aid fitting, aural rehabilitation should be started immediately in accordance with normal development models.Preschool aural rehabilitation program, Ramathibodi Hospital, Mahidol University was established in 2001 to provide an early intervention program for very young deaf children who were diagnosed at Ramathibodi Hospital.It is also available for referral children whose parents are willing to participate in the program.The purpose of the present study was to examine listening and speaking performances of deaf children who enrolled in the preschool aural rehabilitation program for hearing-impaired children at our clinic.

Material and Method
Twenty-seven hearing-impaired children enrolled in the present study.Inclusion criteria were: 1. Less than six years of age with no other handicaps.
2. Bilateral sensorineural hearing loss that was diagnosed by otolaryngologist(s) and appropriate hearing aids fitted by audiologists.
3. Parent and the child must be able to attend the program regularly.
After the children enrolled into the program, listening and speaking ability were evaluated by a team comprising of an audiologist, a speech pathologist, and a teacher in the program.Hearing-impaired children were enrolled into rehabilitation program at various ages and different time, so the children were classified into small groups of 4-6 children based on their performance level at the evaluation process, according to the rating scale in Table 1.Each group attended the program once a week for approximately 3 hours per session.While the children were trained in the program, one parent of each child had to participate in the class and to observe the training in order to continue their training at home.The training session started with group auditory training for 45 minutes, the difficulty level of activities depending on the child's ability, followed by 50 minutes of group conversation (Maternal Reflexive Method) (8)  The listening skills were determined by 5 level rating scale as follow: 0 = No awareness of sounds 1 = Demonstrates conditioned respond to sounds 2 = Discriminates various auditory pattern 3 = Identifies words without lip reading 4 = Understands and respond to common phrases, everyday conversation The speaking skills were determined by 4 level rating scale as follow: 0 = None (no speech) 1 = Imitates varying numbers of syllables or words (imitation) 2 = Naming words after stimulating with pictures or models (prompted production) 3 = Says the words with his own appropriately (spontaneous production) The length of speech production was determined as follow: 0 = None (no speech) 1 = one-syllable words 2 = 2-3 syllable words and phrase 3 = sentence with at least 3 words in the records of all the improvements and problems for each child's progress note and plan for the next session by following the rehabilitation process shown in Fig. 1.Evaluations of each child were done every 6 months (9) .

Statistical analysis
Descriptive statistics was used for analysis of the data.Correlation coefficient was used to assess the relation between age of enrollment, listening skills speech character, number of spoken vocabulary and length of speech, statistical significance at p < 0.05.

Results
Twenty-seven children (12 boys and 15 girls) have been trained regularly for more than 1.5 year and included 14 children who were diagnosed at our clinic and 13 children who were referred from other clinics.The average hearing loss in the better ear was 104 dBHL with SD = 8.33 (range 83-117 dBHL).The mean age of enrollment was 34 months with SD = 14.5 (range 11-60 months).The median hearing age (duration of hearing aid fitting and age of enrollment) was 3 months (range 0-15 months).The progression of listening ability is shown in Fig. 2. At the initial period, most of the children's hearing ability (twenty children) was very poor.They were not aware to sound.Only seven children were at the level of sound detection.After the first six-month of the training period, the twenty children were able to detect sounds consistently, two children were at the level of detection, and five children improved to the level of sound discrimination.At eighteen months, fourteen children were able to identify speech sounds and six children were in the level of comprehension.
For speech production, there were three categories of evaluation including type of speech production, length of speech production, and number of spoken vocabulary.As shown in Fig. 3, at initial evaluation, twenty-one children could not produce any speech.After six months, these twenty-one children were able to imitate speech sounds.Two children did not improve, while four children improved to the level of prompted production.After eighteen months, sixteen children were able to produce spontaneous  2).

Discussion
The preschool training program for hearing impaired children aims to provide aural rehabilitation, especially for deaf children who have limited in speech understanding, even with amplification (10) .Following aural rehabilitation, there was evidence of development of listening and speaking ability in all participants.Twenty-seven children with severe to profound hearing loss who had attended the program regularly once a week for more than one and a half years showed progression in listening skills, speech acquisition, language development, comprehension, and capability to respond to everyday conversation.They were able to participate in daily living activities with hearing people without using signs.This is in agreement with the study of Geers (11) who found that deaf children were able to approach the achievement of hearing children with improved teaching method.Study of Yoshinaga-Itano C et al (12) reported that enrollment in an intervention program by nine months of age compared with later intervention program was associated with improvements of speaking ability.In the present study, there was no relationship between age of enrollment and the speech performance because the average age of enrollment of children in the present study was rather late.The children came from our clinic and referral from outside.Most of the referral children have been fitted with hearing aids and started to train at other centers before enrollment to the program.Some children needed re-hearing aids evaluation because they were not fitted with appropriate hearing aids; therefore, they could not derive maximum benefit from amplification (13) .Some referral children were older than children from our clinic.The result of our study was the same as the study of Calderon and Naidu (14) who compared the vocabulary scores of children enrolled in the intervention program before 24 months of age.They were not different from those enrolled later (p > 0.05).The present study shows a positive relationship between listening skills and speech length, number of spoken vocabulary, and speech character.This means that children who have better hearing will develop longer speech, better speech character, and more spoken vocabulary acquisition.The presented program applied the maternal reflexive method, which focus on maximizing the residual hearing combined with speech reading and early introduction of written words during training (8) .Thus, auditory training is important in development of auditory skills.When children hear words and sounds in combination with written words, it helps the children's ability to produce longer words.If the child hears more speech, the child can easily learn spoken language.No matter how deaf the children are, listening and speaking may be accessed when they are properly fitted with hearing aids and given appropriate and intensive auditory training (15) .
However, many factors influence successful aural rehabilitation for deaf children as in the authors' experience.Firstly, this rehabilitation program was supported by donations.The program could not be managed like an ordinary kindergarten due to limited personnel, place, and budget.There was only one teacher and one assistant to teach all the children.The children could not attend daily training.They participated in the program only once a week.Parents were required to participate with the training program, because parent are the primary rehabilitative agent for maintaining the child's hearing aids and structuring an auditory learning environment rich with listening experiences (16) .Secondly, reliable and valid outcome measurement for infants and young children are limited for several reasons such as lack of co-operation during audiologic testing, physical differences, and limited speech perception ability in infants and young children (17) .For this reason, one benefit of the presented program was monitoring of children's progress, especially after hearing aid fitting.The children will receive training, re-evaluation of hearing capacity, and hearing aid using if there is no progress in auditory development.Thirdly, children who had severely profound hearing loss, even with powerful hearing aids, showed less auditory progress after an extended period of consistent hearing aids use with rehabilitation program.These children are candidates for cochlear implantation, but most parents could not afford the

Table 1 .
Categories of evaluation for hearing impaired-children

Table 2 .
Correlation coefficient between age of enrollment,