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The principal types of regional and local maps in the Middle Ages were itinerary maps, maps of regions like England or Palestine, city plans, and, especially from the very late Middle Ages, maps of disputed lands or boundaries of properties.
Written itineraries were well known in the Middle Ages and were apparently used both as travelersa€™ aids and for armchair travel, often for the purpose of either actual or mental pilgrimage.
The other significant extant example of an itinerary map is the one that appears in various redactions in manuscripts of Parisa€™s Chronica majora. In addition to these surviving examples of itinerary maps, the significance of the itinerary a€” especially the written or narrated itinerarya€”is demonstrated by the frequency with which itineraries served as at least one source for other types of maps. Paris created a number of regional maps of England and Palestine, as well as two historical maps representing features of early Britain.
Matthewa€™s so-called Itinerary from London to the Holy Land, which has been reckoned with his map of Palestine, is not really a connected whole; it is the result of combining two different works, a pictorial representation of the route between London and Apulia (in southern Italy), and a sketch of the Holy Land. Matthew Parisa€™s maps of Palestine are best described as maps not so much of the Holy Land as of the Crusader kingdom, especially since a plan of the city of Acre, the principal port of the kingdom, dominates the coastline. The Itinerary to Apulia is not, therefore, part of a pilgrima€™s guide to the Holy Land; but rather appears to be a political sketch, with the following history (from Beazley). The text of this map of Palestine is, in fact, closely related to various Intineraries of the period of Latin domination in Syria, such as Les pelerinages pour aller en Jerusalem, Les chemins et les pelerinages de la Terre Sainte, or La deuice des chemins de Babiloine (viz. Itinerary Map from London to Bouveis, Cambridge, Corpus Christi College Library, MS 26, f.ir.
Matthewa€™s little red lines become roads, inches become miles, vignettes become cities to be traversed by the viewers of his manuscripts. With the actual city lost to travelers, labyrinths created a space for virtual travel, much in the same way as Matthewa€™s maps do. The maps Matthewa€™s manuscripts contain, even the a€?lineara€? itinerary pages like the one that opens CCCC 26, are not as straightforward as they at first appear.
These labyrinthine maps of Matthew Paris are quite different from those of his contemporaries in important respects. On the Psalter Map, beginning at the top and proceeding clockwise, we encounter the Garden of Eden, the Red Sea, a band of monstrous peoples, Britain, and the gates in the Caucus Mountains, retaining the hordes of Gog and Magog.
Matthew was not immune to the common medieval interest a€“ monastic and secular a€“ in marvels like the monstrous peoples of Africa and Asia, reflected not only by their presence on the Psalter, Hereford and Ebstorf maps, but also by their near ubiquity in texts and images of all types. Just as audiences flocked to see Henry IIIa€™s elephant, they may also flocked to see some of the world maps, such as the Hereford Map, likely displayed in Hereford Cathedral as part of a pilgrimage route dedicated to Bishop Thomas Cantilupe, who died in 1283. Matthew also chooses not to dwell in his maps on the horrifying hordes of Gog and Magog, lurking behind the Caspian Mountains, which is surprising, given his millennialism.
Matthewa€™s maps a€“ from the first legs of the itinerary, branching out from London along two paths, to the (nearly) pathless tracts of the Holy Land a€“ present a range of spatial options to the ocular traveler moving through them. But again, this invites a question: If these maps, which were likely made just after 1250, are millennial, why not populate them with prodigies, with monstrous births heralding doom, with monsters of the sorts found on the Psalter Map, or with images of the people of Gog and Magog, who appear three times on the Hereford Map, once behind their wall and twice already outside of it, released into and upon the world?
Not only is the Holy Land to be inexorably lost, despite the valiant efforts of these last Crusaders, but the invasion of Europe itself is threatened by the apocalyptic Mongol hordes, believed to be Gog and Magog unleashed beyond the frontiers of civilization as harbingers of the end of the world. This is, indeed, the moment of production for the maps, but this is not the moment (or moments) depicted on the maps, themselves.
Connolly translates jurnee, the repeated inscription on the paths throughout the itineraries, as a€?one day,a€? rather than the customary a€?daya€™s journey,a€? perhaps unintentionally conjuring a sense of longing for travel by a cloistered monk a€“ one day, one day a€“ but also for the reclamation of the Holy Land a€“ one day, one day a€“ and, of course, ultimately, the return of Jesus, the end of time, the Last Judgment, and the creation of the Heavenly Jerusalem a€“ one day, one day.
Connolly characterizes the performative experience of walking a labyrinth as a€?a prolonged, sometimes frustrating process,a€? but, after all its disorienting divagations, a€?[a]t the very end of the labyrinth, a straight line appears to lead you directly to the center, to arrive, metaphorically, at the holy city of Jerusalem.a€? Returning to Matthewa€™s map of the Holy Land, (CCCC 16) we find that there is a pathway charted on its largely pathless surface, a road marked out like those of the itinerary pages that precede it.
Matthewa€™s maps seem to present a maze of pathways, but like the labyrinths, present a unitary destination. Itinerary from London to Jerusalem with a description in French, similar to one in the Royal MS. Matthew Parisa€™ Itinerary from Pontremoli to Rome with images of towns, their names, and descriptions of places, with attached pieces, including the city of Rome to the right; from Matthew Parisa€™ a€?Historia Anglorum, Chronica majoraa€?, Royal 14 C. Mascun to the Alps in Matthew Parisa€™ a€?Chronica Maioraa€?, a€?Corpus Christi College, MS 26, fol.
A A A  The principal types of regional and local maps in the Middle Ages were itinerary maps, maps of regions like England or Palestine, city plans, and, especially from the very late Middle Ages, maps of disputed lands or boundaries of properties. While monsters and marvels played an important role on mappaemundi like the Psalter, Hereford and Ebstorf, their role on Matthewa€™s maps is strongly curtailed. The big blow was a ball pounded into the dirt by junior Heidi Morrical that scored the go-ahead run and brought home an insurance run after a Germantown throwing error. Coach Outlet They will follow the life of Captain Bertie Cecil Batey of the Durham Light Infantry from his signing up to his death on the battlefield at Ypres in Flanders. Andrew Cuomo said the state Department of Health would offer free testing of cooling towers and evaporative condenser units, where the bacteria also can hide. He has been the executive director at the Lower MUA since March 2011, according to his Linkedin page.
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Takes credit for others work, which he is known for widely in the area, not just my observation.
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Most of these maps appear to have belonged to separate traditions, although the extensive corpus of maps in Matthew Parisa€™s chronicles, combining as it does multiple map types, suggests the degree to which a graphically inclined author might be familiar with and able to deploy images from all the known categories of maps, in addition to other types of drawings and diagrams.
Only two maps structured as itineraries survive, the more elaborate of which is the Peutinger map (Book I, #120). The map shows the route from England to Apulia, marking each daya€™s journey and prominent topographic features like mountains and rivers. For example, some of the information on the Hereford world map (#226) was based on an itinerary that may show a route familiar to English traders in France. In many ways they continue the itinerary from England to Sicily (Otranto in Apulia was a common point of embarkation for Acre).
CCCC 26 contains the annals from creation to 1188, CCCC 16 from 1189 to 1253, and Royal 14 C.viii from 1254 to 1259, when Matthew died. These contain images of cities, connected by clearly marked roads inscribed journee [a daya€™s journey].
This mode of associating travela€™s a€?microa€? with its a€?macro,a€? as it were, was of increasing significance in the 13th century, when pavement labyrinths were either first used in European churches or were newly popular. And by presenting its audiences with a richly meaningful image of the city of Jerusalem a€“ one whose centrality in the nave mimicked that citya€™s centrality in the world and whose fundamental geometry signaled a cosmic architecture a€“ this pavement triggered associations with the city, both in its earthly and historic instance and with its future, heavenly instantiation, and it did so as it invited its audiences to perform an imagined pilgrimage to this sacred center.


Labyrinths allowed church visitors to travel short distances in the densely confined knots of their paths, while simultaneously travelling to the very a€?centera€? of the world, emphatically emphasized by their symmetrical forms. Perhaps unsurprisingly, they are filled with problems, and become a€?very muddled and confusing,a€? with cities that are a€?misplaceda€? or appear twice. The well-known Psalter Map, for example, is a typical mappamundi, displaying the entire ecumene, that is, the inhabitable world, as known to 13th century English cartographers (#223).
Wonders of this sort are not incidental to the function of medieval maps like the Psalter; rather, they are essential components thereof, supplying a necessary antipode to a central Jerusalem, rooted in biblical and patristic texts. Matthew represented marvels known from monster cycles like the Marvels of the East and the Liber monstrorum, and from contemporary narratives about cultural others like the a€?Tartarsa€? a€“ a medieval Christian term for the Mongols a€“ but also from personal observation, such as the elephant given by Louis IX to Henry III, which appears as one of the prefatory images appended to CCCC 16.
As Dan Terkla writes in a€?The Original Placement of the Hereford Mappa Mundi,a€? Imago Mundi, vol.
They are wholly absent from the itinerary maps, and appear in a limited scope on the Holy Land maps a€“ CCCC 16). Roughly centered, on either side of the gutter and just above the wall of Acre, are two large blocks of text. These are not, to my observation, a common feature of the maps, and of course I cannot speculate on the date of this erasure.
In contrast, the Ebstorf map, for example, gives us a gory presentation of these cannibal hordes. For Matthew and his contemporaries, there existed only one future, and its expected arrival was nearly coincident with his creation of the maps.
One response might be that the sorts of monsters found on the Psalter Map and other mappaemundi were seen as normal elements of creation, rather than as portents of the apocalypse.
Returning to Matthewa€™s off-center image of Jerusalem, we find that the three structures it contains are not as they were at the time of the mapa€™s creation. The journey may be long a€“ at least 46 days in Lewisa€™s reckoning a€“ and the path may not be singular or even, further out on the journey, marked at all, but one day, one day, one day, for Matthew anda€?his monastic audience, one day the reader would at last arrive. Their path from town to town has the appearance of being perpetually straight and direct, but in fact would twist and turn. Just beneath Jerusalem, inscribed in red and oriented ninety degrees counter-clockwise to the rest of the map, again following our orientation from our bodies, forward, we read le chemin de Iafes a Ierusalem [a€?the road from Jaffa to Jerusalema€?]. Here we seem to see movements in space as we traverse the paths a€“ initially forking for Matthew, but ultimately as singular on his maps as on the labyrinths. This is surely the case, more often than not, but medieval maps are frequently anagogic, pointed a spiritual meaning only to be realized in a heavenly future. The extension of its city walls to the left show the fortifications constructed by St Louis during his crusade in 1252-4. Babylon of Egypt).A  The first of these is of 1231, the second of 1265, the third of 1289-1291, but it is probable that earlier redactions of the last two already existed in Matthewa€™s time, and were used by him.
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A 12th or early 13th century copy of a Late Antique original, the map has usually been studied for what it can tell us of ancient cartography or of the interest in the ancient world on the part of the 15th century German humanists who rediscovered it.
Suited to its location in a chronicle, the map serves a historical purpose in demonstrating the route of a well-known contemporary diplomatic expedition, Richard of Cornwalla€™s expedition to Sicily in 1253 as the claimant to the crown, although the map contains information drawn from multiple journeys and routes. For example, the Hereford map incorporates an itinerary through France and possibly one in Germany. Of the historical maps, one is a sketch showing the location of four pre-Roman roads in Britain. I will concentrate on the maps appended to the beginning of the first volume, though similar maps appear at the start of all three volumes, suggesting their great importance to Matthewa€™s conception of the Chronica, his major work. Each column, then, represents a segment of the voyage from London, at the base of the first column of folio i r, through Sienna, at the top of the final column of the itinerary on f. It is worth mentioning that the Psalter Map is only a few inches tall, and that the whole codex fits comfortably in the hand, unlike Matthewa€™s larger, more cumbersome (and ever-expanding) volume. In essence, the center is presented as sacred and the margins as problematic, potent, and potentially monstrous, but also thereby seductive and attractive. This may result from the shift from counterpunctual arrangement of sacred center and monstrous margins on the Psalter, Ebstorf and Hereford maps, among others, to the less clearly structured arrangement of Matthewa€™s maps. Both are of a somewhat marvelous vein: to the left of the gutter, we read of Bedouins, whose description is reminiscent of wonders texts like the Marvels of the East. In the Chronica and contemporary accounts, Gog and Magog are conflated with the two most prominent cultural Others perceived as threats to 13th century a€?Christendoma€™: Jews and Mongols. Second, and more importantly, the choice to include or exclude such images might have been predicated on chronology. If those mental wanderings took them to the right destination, they would realize the function of the labyrinths rather than contradict them. Very quickly however, the labyrinth focuses your concentration on the path, else you are likely to stray from it.
In walking a labyrinth, virtual pilgrims orient themselves to its shifting orientation; in traversing the itinerary, the world is bent, reorienting itself constantly to our perspective, making the shift to the trackless conclusion, the map of the Holy Land, all the more powerful.
However, since the endpoints on Matthewa€™s maps and at the centers of the labyrinths are the Heavenly Jerusalem, the motion is as chronological as it is geographical. That is, while medieval maps are organized spatially, they are in a sense oriented temporally. The de-centered maps of Matthew, unlike the labyrinths or the Psalter Map and its cognates, do not announce their radial orientation toward Jerusalem. At the upper left is the enclosure in which Alexander confined Gog and Magog, but Matthew notes that they have now emerged in the form of Tartars.
Albans, a portion of the supposed Pilgrim-road, as far as southern Italy, is given in another shape, together with the Schema Britanniae. Appropriate holistic intervention is essential for the development and quality of life of the child.
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It is, however, extremely important to remember the commitment of time and resources involved in producing the medieval copy: the question then arises of what this map meant to the society that found the human and financial resources to copy it.
Parisa€™ map of Palestine draws on the kind of information about the length of the journey from city to city that would normally be found in an itinerary as an indication of scale for the map. Harvey has suggested that the maps of England and the Holy Land might be seen as enlargements of the end points of the itinerary. Daniel Connolly in his book The Maps of Matthew Paris: Medieval Journeys through Space, Time and Liturgy writes that Matthew began the Chronica majora a€?as a fairly strict copy up to about 1235, of Roger Wendovera€™s Flores historiarum [Flowers of History].
There is, though, a more substantive manner in which the itineraries break down their apparent linearity: they a€?forka€? from the very start, with two paths diverging from London.
Still, the Psalter Map remains a strong point of comparison for two reasons: first, it was made within perhaps a dozen years of Matthewa€™s maps. While Iain Macleod Higgins (Defining the Eartha€™s Center) is correct that a€?the viewer of a circular map can never quite lose sight of a well-marked center, since the very shape of the map keeps onea€™s gaze circling around it,a€? by the same logic, we cannot lose sight of the periphery for long, and the visual attention given to the monstrous peoples of the South, as well as the other peripheral points of interest, keep pulling the gaze back. Matthew managed through his texts, marginal illustrations and maps, to bring the whole of the world and its history, from Creation to the present, from sacred Jerusalem to the monstrous elephant, to himself and his monastic brethren. In contrast, a€?[t]he main audience for [Matthewa€™s] maps doubtless was the brethren at St. Unlike these other maps, Matthewa€™s maps of the Holy Land de-center Jerusalem and, since it is not replaced with anything else, they do not have a clearly defined umbilicus.
To the right, more promisingly, we find a passage that begins, in Lewisa€™s translation, a€?There are many marvels in the Holy Land, of which [only a few] shall be mentioned.a€? However, these marvels are, in comparison to the Wonders of the East and other such texts, somewhat anemic. Indeed, these beasts a€“ fairly ordinary to modern eyes a€“ do appear just above the two- faced people in the Beowulf manuscripta€™s version of the Wonders of the East. Muslims occupied the Holy Sepulcher, as well as the Temple of Solomon a€“ home of the Knights Templar a€“ and the Temple of the Lord by 1250. By tracing their routes on foot or on their knees, virtual pilgrims would hope to reap spiritual rewards akin to those gained on pilgrimage, effecting peregrinatio in stabilitate a€“ that is, pilgrimage without moving. There is a second pathway, also rubricated and turned ninety degrees, at the right edge of the map.
Yes, they are oriented toward the east, but on several mappaemundi, beyond the east, it is Jesus who rises. Instead, they challenge the viewer to work though them slowly, meditatively, to explore and wander as we do in life. This study describes the co-morbidities within the field of occupational therapy, speech therapy and physiotherapy that pre-school children with hearing loss present with at the Centre for Language and Hearing Impaired Children (CLAHIC) and its implications for management. Louis Vuitton Outlet Online Since the beginning of the year, the number of people who have crossed the threshold from food insecure to severely food insecure, also rose, jumping from 2.5 million in January, to 5 or 6 million now, as the lean season begins.
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Unfortunately, theactions undertaken byNATO countries under these resolutions led totheir grave violation andsupport forone ofthe parties tothe civil war, with thegoal ofousting theexisting regime, damaging inthe process theauthority ofthe Security Council.
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It has been plausibly explained in the context of the strong interest in the classical world that we have already seen influencing the toponyms of later medieval world maps; however, more research should be done to elucidate the importance and the influence of this map.
In 1240, or soon after, Matthew started writing, covering the material from 1235 and continuing to the middle of 1258, at which time another hand takes over.a€? These maps, along with the marginal images throughout the Chronica, have been securely attributed to Matthew himself and, according to Suzanne Lewis in her The Art of Matthew Paris in the Chronica Majora a€?may be regarded in large part as original conceptions and inventions,a€? rather than derivatives of traditional models.
Second, unlike some mappaemundi, including Hereford (#226) and Ebstorf (#224), the Psalter Map was not freestanding. Indeed, two of the three sites were originally Muslim structures a€“ the Temple of Solomon was a mosque and the Temple of the Lord was the Dome of the Rock a€“ and they had reverted to Muslim control by the time the maps were made. The labyrinth is at first a challenge of some dexterity, and so it also foregrounds your sense of balance and of bodily position relative to it. The maps echo and invoke the actual experience of pilgrimage, which a€“ like modern travel a€“ was surely bewildering, disorienting, but also amazing. The Hereford, Ebstorf, and the Psalter maps are all oriented not only toward Earthly Paradise at their eastern extreme, but beyond it to the creator of that paradise. They become all the more powerful, therefore, when their off-center, deemphasized Jerusalem turns out to be the only and inevitable end. Prior to the beginning of each session, the agents were informed that providing false testimony to the body was unlawful. And a few of Ortega’s twelve brothers and sisters live in the area and help out on the farm.
Wholesale Jerseys "This report is relevant to persons who are seriously ill, their parents, children, extended families which essentially means every American," said VJ Periyakoil, director of Palliative Care Education and Training at Stanford University's School of Medicine, who was not involved in the report.
He assigns her to the island to research immortality, and she suspects the key to realizing it lies in the pre-teen Natalia, another prisoner.
Shapcott describes Golf Revolution as the “yoga model”—you join a club and drop in for as much or as little training as you want in a pay-as-you-go way. These interconnections are especially striking in the rich cartographic production of Matthew Paris. On the peripheries of both maps, we see the Garden of Eden, the Red Sea, a plethora of monstrous peoples, and the hordes of Gog and Magog (feasting in bloody cannibalism, on the Ebstorf and also, perhaps, on the Hereford).


In CCCC 26, the center would be just east of (that is, above) the crenellated wall of Acre. In a sense, this follows the logic of the mappaemundi discussed above; we appear to have zoomed in on the center of these maps, to focus on the area around Jerusalem, which would necessitate cropping the worlda€™s monstrous fringe.
Like medieval labyrinths, Matthew Parisa€™s maps were not mazes per se, in that there are not alternate routes leading to dead ends: both contain singular paths. At the same time, there is a loss of your sense of a€?placea€? in the church as orientations are constantly shifting and revolving. So, too, while these maps are centered on Jerusalem, this umbilical point presses the viewer to consider the future.
The first columns contain cities connected by clearly marked paths; these are followed by columns with cities still arranged in clearly linear fashion, but without the marked paths. The BND agents repeatedly insisted that the selectors provided by the US were precisely checked.
It's also Natalia who greets Barry when he arrives on the island six months after Claire and Moira's escape attempt, searching for them. The name riffs on Matson's love of traditional folk textiles and patterns that inspire and become incorporated in her work.
CCCC 26 opens, following the flyleaves reused from a manuscript of canon law, with a series of linked maps running from folio i recto through iv recto (the lowercase Roman numerals indicate the status of these folios as prefatory).
The Psalter Map is one of two that form a sort of series, like Matthewa€™s maps, with one more geographical and one more linear, text replacing itinerary but no less clearly directional and effacing of actual geographic arrangement.
Jerusalem a€“ so ardently central on the Psalter Map a€“ is shunted off to the right by Matthew.
However, if we assume some consistency of geographical space from map to map, Matthewa€™s expansive map, filling the complete manuscript opening and extending out onto added flaps of vellum, does reach to the margins of the world. Matthewa€™s paths seem to fork out from London, but ultimately all converge at one geo-chronological endpoint, at a place that is also a time: the Heavenly Jerusalem, at the center of the physical world and simultaneously the end of human history. Its movements to and fro, back and forth create a regular and somewhat wearying effect that combines with the hypnotic vision of the pavement receding beneath your alternating steps.
Then, the linearity ends, and we are left with images that are more conventionally a€?map-likea€? in their appearance. Using a non-probability, purposive sampling strategy the records of 62 children diagnosed with a hearing loss that attended the CLAHIC from 1999 to 2010, were reviewed. The insurgents want to carve out a separate state governed by their strict interpretation of Islamic law, and some have links to the Islamic State group.
We are able to choose our path to the Holy Land a€“ should we, leaving London, travel via the main route, Le Chemin a Rouescestre [the Road to Rochester] or the side route, le chemin ver la costere et la mer [the road toward the coast and the sea]? Indeed, before the late-13th century insertion of additional prefatory miniatures, it was positioned before its text as a sort of frontispiece, as are Matthewa€™s, and was also one of a series of maps. He adds an inscription referring to Jerusalem as a€?the midpoint of the world,a€? which seems visually contradicted by his map, whereas such an inscription would have been redundant on the Psalter Map. At the upper left corner of the foldout flap along the folioa€™s left edge, as if to ensure the clarity of their separation from the Holy Land, are the peoples of Gog and Magog, visually implied by the wall of the Caspian Mountains, held there until the end of time, when they are to be released to rampage across the face of the earth. Instead, it presents the period before, but also simultaneously, the period after, the transient, lost glory of the Crusader Kingdom and the immutable glory of the Heavenly Kingdom to come.
Like the labyrinthsa€™ single paths, Matthewa€™s many roads can only guide the viewer toward one destination.
Most images function spatially, not linearly, but the itinerary pages present a line or course of travel; a route, much as a text would. Once in the Holy Land (CCCC 16), we are free to choose any routes we desire, as the roads themselves disappear (up until the very end, as will be discussed below). The Psalter Map, like medieval labyrinths, is emphatically centered on Jerusalem a€“ following a new 13th century trend a€“ and around its circumference, we find points of great interest. The Caspian Mountains, restraining the hordes of Gog and Magog, actually touch the very margins of the world on the Psalter and Ebstorf Maps, and nearly do so on the Hereford Map.
They prepare and condition the viewer, raising an expectation that the maps will function in a linear fashion, and thereby convey motion in time as well as space. Upon hearing that the Mongols a€“ feared by Christians to be the apocalyptic hordes a€“ are making progress toward Europe, he imagines that continental Jews a€?assembled on a general summons in a secret place, where one of their number who seemed to be the wisest and most influential amongst thema€? instructs them to undertake a complex plot to smuggle arms to the Mongols, so that they can defeat the Christians.
The final segment of the path a€“ le chemin de Iafes a Ierusalem [the road from Jaffa to Jerusalea€?] a€“ realizes this expectation. Further findings indicated that co-morbidities of hearing loss are independent of the degree of the hearing loss.
Matthewa€™s fantasy is not merely xenophobic, but outright eschatological, a vital distinction in the context of the maps of CCCC 26.
If the Mongols (or the Jews, or for that matter, the Mongols and Jews, or even the Jewish Mongols) are the hordes of Gog and Magog, then they have already broken out of the gate prophesied to contain them until the apocalypse.
It reads, Le chemin de laphes a Alisandre.a€? This seems to be a vestige, a latent echo of the itinerarya€™s multiple paths.
Access to appropriate healthcare and resources, financial costs and appropriate educational placement are just some of the possible challenges that are intertwined in the dynamic decision-making and management processes for these children. In the presence of co-morbidities in addition to a hearing loss, an interdisciplinary team approach to intervention that incorporates ongoing collaboration amongst the professionals in the team is proposed. It is therefore imperative that referral systems are established between health care professionals working in these settings to facilitate collaboration and ultimately the best possible outcomes for children with hearing loss and their families. There are predominantly three different types of hearing loss namely, sensory-neural, conductive or mixed hearing loss. A sensory-neural hearing loss is the result of a problem with the inner ear or the auditory nerve8 and is usually permanent in nature.
Intervention could include hearing amplification such as hearing aids or cochlear implants and aural rehabilitation.
A conductive hearing loss is a problem in the outer or middle ear and is often medically or surgically treatable7. The point at which a person starts to hear sound is referred to as a dB of 0 and normal hearing for children is described as being between 0 and 15dB.
It has been reported that in the case of genetic hearing loss, 30% is syndromic and therefore associated with specific abnormalities10-Syndromes that are commonly associated with hearing loss that were identified in this study included Goldenhar Syndrome, which is a congenital malformation syndrome predominantly affecting facial appearance11, Waardenburg Syndrome described as a heterogeneous disorder affecting the auditory system and pigmentation of the hair, skin, and eyes12, and Connexin 26 mutation known as mutations that occur in the Connexin 26 gene and are associated with sensory-neural hearing loss13.
Environmental causes of hearing loss include excessive cerumen, noise exposure, infectious diseases (e.g. In the present study a comorbidity will refer to a disorder that is in addition to hearing loss. Co-morbidities of hearing loss include motor impairment, cognitive or learning difficulties (LD), global developmental delay described as a significant delay in two or more developmental domains14, sensory integration (SI) impairment that occurs when there is a disruption in the neurological process that organises sensation from the body and the environment15, communication disorders such as verbal apraxia, attention deficit-hyperactivity disorder (ADHD) and other medical, physical, or emotional problems16. The other prevalent co-morbidities of hearing loss that have been identified are sensory integration disorders and motoric problems16. Suarez et al.16 noted that sensory-motor problems were found in children with a hearing loss who attended mainstream schools and used spoken language in their communication. In addition, they found that children with sensory-neural hearing loss appeared to experience more difficulties with vestibular processing when compared to their typically developing peers with normal hearing16.
It is postulated that these difficulties result in delays in the development of gross motor skills.
One approach to the holistic management is the interdisciplinary team approach when team members collaborate to produce a comprehensive intervention plan17.
It further promotes the responsibility of each team member, including the parents who are considered to be the most important members of the team, to achieve the child's outcomes18. Concern about the child's developmental skills may warrant referrals to the relevant specialists, such as a speech-language therapist, an occupational therapist, physiotherapist, psychologist and otolaryngologist. Early intervention for infants and children with hearing loss should build communication skills that will facilitate social and cognitive development16. For children with hearing loss that also present with co-morbidities, early intervention that is interdisciplinary in nature is even more critical. Educational programmes should ideally offer an integrated curriculum that nurtures speech, language, literacy development, innovations in the areas of auditory perception, social emotional learning, motor development, and vestibular function to enhance outcomes22. Inclusive programmes in the clinical pre-school setting, that maintain small class sizes and use a co-teaching model, can provide differentiated teaching. This study is an attempt to determine the co-morbidities of hearing loss in pre-school children.
It is proposed that this information could guide the development of intervention protocols for this population within an inclusive and interdisciplinary educational setting. In order to achieve the primary aim, the prevalence of the different types of co-morbidities was identified and the services provided to these children described.
A secondary aim of the study was to determine if there was any relationship between the severity of the hearing loss and the co-morbidities identified. The CLAHIC has six classes with only eight children per class, and offers a range of additional professional services to the children and their families if required.
These services include audiology, speech therapy, occupational therapy, physiotherapy and educational psychology. The checklist comprised of six sections: Section one and two contained biographical information and hearing status. Confirmed diagnosis of ADHD by a paediatric psychiatrist, learning disorders diagnosed by an educational psychologist and visual impairment identified by an optometrist, were also recorded in this section.
The co-morbidities identified were based on the test results and findings of individual assessments (and subsequent diagnoses) detailed in each of the professionals' report. The researcher obtained ethical clearance from the University of the Witwatersrand's Research Ethics Committee before the research was conducted.
On admission to the CLAHIC, parents sign and provide consent that information from their child's file may be used for research purposes. Confidentiality was assured as files were allocated a participant number and no identifying information was reported. Data were captured on a MS Excel spreadsheet and thereafter tabulated into ordinal categories for statistical analysis. A coding method of using 0 as false indicator and 1 as a true indicator for the co-morbidity present was implemented. Pivot tables were created to interrogate the data as well as perform calculations within the various sets of data.
Descriptive statistics were utilised to analyse those data, and included averages, range, SD, frequency and percentages. The use of the term reliability in communication disorders research is related to the general trustworthiness of the data and is synonymous with dependability, consistency, predictability and stability24. Observer bias was eliminated as there was no contact with participants and therefore increased the reliability of the study.
To ensure reliability of the recording of information, the researcher, who is familiar with the settings of the CLAHIC, had complete administrative control over the data collection. A comprehensive literature review was conducted and served as an underpinning for the measurement instrument of this study, the checklist. The data collected from the pilot study was used in the final analysis of the main study to add to the sample size, and it can therefore be referred to as an internal pilot28. Fourteen participants' files of 2009, who met the inclusion criteria as for the main study, were included in the pilot study. The researcher converted the information from the pilot study into numerical data that were collated onto a MS Excel spreadsheet for analysis. The degrees of hearing loss ranged from moderate to profound, with the majority of participants (47%; n = 29) diagnosed with a profound hearing loss.
Of these, congenital anomalies, such as cleft-lip and palate, respiratory conditions and dysmorphic features, were evident in 15% (n = 9) of the participants, whilst 11% (n= 7) were diagnosed with a syndrome prior to admission into the CLAHIC. These syndromes included Goldenhar syndrome (n = 2), Waardenburg Syndrome (n= 1), Connexin 26 mutation (n= 1) and Respiratory Distress Syndrome (n= 2). Sixteen percent (n = 10) were born prematurely and 6% (n = 4) of the participants had very low birth weights. Each co-morbidity was diagnosed by the relevant specialist based upon assessment findings for each child. The co-morbidity of a gross-motor delay diagnosed by a physiotherapist was 18% of the participants (n = 11) that included disorders in postural control and positioning, flexion and extension control and balance integration. Sixteen percent of the participants (n = 10) presented with verbal apraxia and received intervention by speech therapists. Referrals to a geneticist for genetic testing after admission to CLAHIC were limited to 3% (n= 2) of participants.
Of these participants, 52% (n= 12) presented with a delay in fine motor skills, whilst the remaining participants presented with visual motor integration difficulties. Nineteen percent of participants (n= 12) were recommended to continue at the CLAHIC, whilst a further 19% (n=12) were referred to schools that offered education using sign language. The remaining 10% of participants were referred to schools for learners with special educational needs. These specific co-morbidities included delays in fine and gross motor delay as well as VMI disorders.
Research has found that auditory deprivation as a result of pre-lingual deafness may lead to the atypical development of specific motor skills29. It is postulated that the fine and gross motor skills that share the same cortical processes as language, may specifically be delayed29. It is suggested that compounding factors such as (i) the age of identification of the motor delays, (ii) parental involvement, and (iii) early intervention, could influence the outcomes of these children. This is confirmed by Rajendran and Roy30 who found that children with hearing loss and co-morbid motor impairments presented with significantly lower health-related quality of life as well as a result of sub-optimal levels of functioning. This necessitates the provision of appropriate, multi-disciplinary intervention for children with hearing loss and co-morbid motor difficulties. The children who had VMI disorders also presented with fine motor difficulties and had hearing losses that ranged from moderate to profound degrees.
A VMI disorder is the ability of the eyes and hands to work together in smooth, efficient patterns and it involves visual perception and eye-hand co-ordination26. As the vestibular system is linked to the visual system, it plays an important role in eye movements which could influence spatial awareness and fine motor co-ordination31.
It has been reported that difficulties within the vestibular system may further contribute to sensory seeking behaviour, hyperactivity and distractibility due to the influence of vestibular problems on muscle tone31.
This was confirmed in a study that found that children that have difficulties with auditory processing, as well as vestibular processing, have difficulties with body movement and motor planning31.
Cochlear implants are surgically implanted electronic devices coupled to external components that provide useful hearing to children and adults with severe-to-profound hearing loss and ultimately leads to improved spoken communication32.
It is postulated that in addition to more age-appropriate language development and improved levels of self-confidence, cochlear implants may have a positive effect on motor performance and vestibular function in these children32,33. Contradictory findings however highlight the potential risk of vestibular deficits after cochlear implantation and thus motor function34. Findings from the present study concurred as all of the children who had SI disorders also had articulation errors.
This supports findings of other studies that indicated that auditory deprivation, as in the case of a hearing loss, may lead to atypical development of specific motor and language skills that share common cortical processes29.
Importantly, the findings of this study demonstrate that occurrence of the co-morbidities of hearing loss is independent of the degree of the hearing loss, and confirms the fact that all children with hearing loss may be at risk for delays in a range of skills. The increased risk for delay in fine- and gross motor skills development as well as VMI, BI, SI and vestibular disorders noted in this study, highlights the role of the occupational therapist as an important team member in the management of pre-school children with hearing loss. As the educational placement of a child with co-morbidities of hearing loss can be a complex process it is imperative that there is effective collaboration between healthcare professionals and those professionals working in the educational setting.
The case manager should be a professional who has qualifications and knowledge of all developmental areas of the child and should be someone who does not see the child for rehabilitation and can thus be the objective manager as well as liaison between families and professionals. The results of this study should be cautiously interpreted in light of its small sample size and context limitations. Further research should address the replication of this study with a larger sample size in various pre-schools that include children with hearing loss to allow for the generalisation of findings to the broader South African context. In addition, the relationship between the degree of hearing loss and the presence of co-morbidity should be determined   REFERENCES 1. Danermark B, Cieza A, Gange J, Gimigliano F Granberg S, Hickson L, Russo L, Stomgren JP Stucki G, Swanepoel D.
International classification of functioning, disability, and health core set for hearing loss: A discussion paper and invitation. Shi G, Gong L, Xu X, Nie W, Lin Q, Qi Y GJB2 gene mutations in newborns with non-syndromic hearing impairment in Northern China.
Developmental delay: when to suspect and how to investigate for an inborn error of metabolism. Controversies in the field of hearing impairment: Early identification, educational methods, and cochlear implants.
Mellon NK, Ouellette M, Greer T, Gates-Ulanet PAchieving developmental synchrony in young children with hearing loss. Infant hearing screening at maternal and child health clinics in a developing South African community.
Divergence of fine and gross motor skills in prelingually deaf children: Implications for cochlear implantation. Comparison of health related quality of life of primary school deaf children with and without motor impairment.
The sensory profile of children with speech and language disorders in London and the South of England.



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