The difficulties that children with PMLD have in making sense of sound.
The auditory world can be over-bearing, noisy and confusing and at times become a cacophony of conflicting sounds. For a child with complex needs, sound has been described as “blooming, buzzing confusion” which comes and goes. It is a constant challenge to try to understand what these children actually hear and how they process sound.
Children with profound and multiple learning disabilities (PMLD) often have difficulties filtering out dominant visual information and may be unable to cope with and process visual and auditory stimuli at the same time; they can very easily become sensory-overloaded.
Sound can be very unpredictable and confusing. Children with PMLD and those with autism find it very difficult to regulate and filter sound internally. Children with complex needs are often very afraid of dogs and babies crying due to the sudden onset of the sound.
Sound is a transient stimuli and can be meaningless to a child with complex needs unless they are taught and helped to explore and understand different sounds. By its nature, hearing is temporary; sound comes and then is gone.
Young children with complex needs can benefit enormously from structured listening sessions through intensive interaction and play in order to try to focus on specific sounds or musical notes to help them to understand that sound carries meaning. A child with multi-sensory deficits is likely to have a poor auditory memory which significantly affects their perception of a stimulus, and they may require many repetitions of the same listening experience. Similarly, children with PMLD are likely to have significant sensory processing issues and require support and time to process auditory information.
Opening up communication
Given the difficulty in accurately assessing the hearing levels of these children and young people, it can be a challenging task to fit hearing aids and set up cochlear implants for them. Most children with PMLD are likely to be non-verbal and require augmentative and alternative communication systems. This raises the question: what are we trying to aid? What are our expectations when promoting and developing auditory listening skills (and/or fitting hearing aids) for a child with complex needs?
Hearing may be the predominant “window” on the world for a child with a significant visual impairment and the benefits of enhancing their listening skills may be much greater than it first appears.
Improved listening can aid communication, especially to support intentional vocalisations; it may enhance environmental awareness and social interaction, and increase a sense of connectedness with the outside world. Crucially, it may make the exploration of sound and music accessible. Additionally, by stimulating active listening, it may assist in overall sensory integration and reduce unhelpful sensory seeking behaviours.
A study by Donaldson, Heavner and Zwolan1 (2004) described the progress of seven cochlear-implanted children, aged between three and nine years at implantation, who had been using their implants for between six months and five years. Four children were diagnosed with autism and two with pervasive developmental disorder, with a range of severity of presentations and disabilities. This revealed benefits in terms of improved eye contact, awareness of the environment, reaction to music, vocalisation, use of sign language, and response to requests.
Music to their ears
There are many ways to help a young child to engage with sound, but music is most often highly motivating to a child with complex needs. The dynamics of music provide a form of intonation that is more varied and interesting than speech. The rhythmic component of music is very organising for the sensory systems of individuals diagnosed with autism and other additional difficulties. It is thought that these children and young people like the predictability of a song with a distinct beginning, middle and end; it appears that music which is simple with clear and predictable patterns is most effective in eliciting responses to joint attention activities.
Despite difficulties in the areas of socialisation and communication, there is evidence to suggest many individuals with autistic spectrum disorder show a strong and early preference for music and are able to understand simple and complex musical emotions. It has also been found that young people with autism tend to show elevated pitch discrimination ability and superior long-term memory for melody.
Music can also be used for calming and reducing arousal levels, and may also filter out unpredictable and unwanted noise.
Sung jingles and short musical cues can provide more information about a change in activity or transition than simple spoken words, and help to reduce anxiety levels.
Listening skills training can occur at any time throughout the day, either in more structured play activities or simply as the child goes about their daily routines. Again, a consistent little jingle for a daily routine can help with “labelling”, so that the child becomes aware of what is about to happen.
In more structured listening sessions it is beneficial to provide a safe listening environment free from other stimuli and sensory clutter and distractions. Ideally, listening activities need to be conducted in a very low distraction environment with minimal visual stimuli.
Ideas for promoting listening skills in children with PMLD
Start with simple engagement through intensive interaction, using the same action rhyme, and this can be used as an introduction to “listening time”. Sometimes singing or beating a drum in time to a child’s natural body movement (such as rocking or swaying) can capture their attention and start a reciprocal interaction.
The first stage of listening needs to focus on detection, starting with a “start” and “stop” activity to music. This may involve playing a simple percussion instrument and observing the child’s responses when it stops. Always allow time for silences, as these are an important part of the listening process. It is important to observe closely any response that the child may make to request “more” and inform that they have heard the sound/music.
In order to develop listening discrimination it can be useful to follow the child’s own vocalisations through mimicking them with voice or an instrument, and observe when a child may start intentional turn-taking. This can slowly start to develop into a musical “conversation”.
In the longer term, as a child’s listening skills become more established and consistent, an element of choice can be introduced so that the child can start to show preferences. Initially, this may be supported through objects of reference for two contrasting sounds (ensuring the same object is used in each session, such as small plastic boat for Row Your Boat), or through the use of switches, for example.
Jane Douglas is a Specialist Audiologist at Seashell Trust which provides education, care and outreach services for children and young people with complex communication and learning needs: