Download First Voice Deloitte Access Economics Literature Review, February

Comparative review of reported outcomes from
interventions for children with hearing loss
First Voice
Final literature review
5 January 2017
Glossary
i
AOT
auditory-oral therapy
ASL
American Sign Language
AVT
auditory-verbal therapy
ECIA
Early Childhood Intervention Australia
JCIH
Joint Committee on Infant Hearing
LOCHI
Longitudinal Outcomes of Children with Hearing Impairment
LSL
listening and spoken language
PCHI
permanent childhood hearing impairment
SSD
Sign Supported Dutch
Comparative review of reported outcomes from interventions for children with hearing loss
Contents
Glossaryi
Executive summary
1
1 Introduction
3
1.1 First Voice
3
1.2 Childhood hearing loss in Australia
5
1.3 This project
6
1.4 Report structure
8
2 Pathways for children with hearing loss 9
2.1 Listening and spoken language 11
2.2 Total communication
11
2.3 Sign language
12
2.4 Cued speech
12
2.5 Summary
13
3 Common characteristics of successful interventions for hearing impaired children
14
3.1 Multi-disciplinary team
14
3.2 Family-based practices
14
4 Overview of findings
15
4.1 Variables that impact outcomes
17
4.2 Early development outcomes
18
4.3 Learning and later outcomes 22
4.4 Social and wellbeing outcomes
25
4.5 Outcomes of multi-disciplinary interventions and family-based interventions
26
Conclusion27
References 28
Appendix A: Summary of studies included in the review 33
Limitation of our work
36
iii
Comparative review of reported outcomes from interventions for children with hearing loss
Executive summary
First Voice commissioned Deloitte Access
Economics to undertake a literature review
of the measureable outcomes arising from
different communication learning pathways
for children who are deaf or hearing
impaired. The purpose of the review was to
ascertain the effectiveness of the listening
and spoken language approach provided
by First Voice centres for children who are
deaf or hearing impaired compared with
other models of learning language. Findings
also serve to inform the subsequent cost
benefit analysis.
The context for the review is the
introduction of a ‘disability services market’
under the new National Disability Insurance
Scheme (NDIS) in Australia. An essential
prerequisite for any market to succeed is
reliable and accessible information. This
is required both to enable consumers
to make informed decisions and for
the funding authority (in this case the
Commonwealth Government National
Disability Insurance Agency (NDIA)) to
ensure that public funding for early
intervention programs is directed through
eligible NDIS participants to evidencebased providers with proven outcomes.
First Voice is the national voice for six
member organisations whose primary
focus is the provision of listening and
spoken language (LSL) therapy services
in Australia and New Zealand. Each
organisation provides early intervention
services to develop listening and spoken
language skills in children and infants
who are deaf and hearing impaired.
This is a family-based, multi-disciplinary
model which predominantly utilises
auditory-verbal therapy and auditoryoral approaches.
The approach adopted for the review
comprised seven key steps, as outlined
in Figure i.
1
The measureable outcomes of interest for
hearing-impaired children are outlined in
Section 4. These were:
•• Early development outcomes
(communication, speech, language)
•• Learning outcomes (school and
post-secondary)
•• Life-long social and wellbeing outcomes.
These outcomes align with parents’
aspirations for their child, service provider
objectives, and the goal of the NDIS
“to optimise the social and economic
independence of people with disabilities”.
Most information retrieved related to
early development speech and language
endpoints. Across the broad range of
articles retrieved, some common shortfalls
were observed. These were small sample
sizes, a reliance on self-reported data, no
comparison group and the retrospective
nature of studies. Put simply, evidence
based literature with a strong study design
and demonstrated sustained effect at
least one year beyond intervention was
not found.
The available evidence shows that the
most effective pathway for hearingimpaired children in bringing about early
development and schooling outcomes is
early intervention in the context of a multidisciplinary team and with high levels of
family involvement.
A multi-disciplinary approach is seen
as vital to the development of children
with hearing loss. This is because of
the complexity of developing fluent
communication in pre-lingual children
who are deaf or hearing impaired and
the need for shared expertise and close
collaboration between the key disciplines
of spoken language therapy, paediatric
audiology, speech pathology, deaf
education, family counselling and relevant
Figure i: Literature review methodology
Steps
1 Define research questions
2 Identify key search terms
3 Systematically apply search criteria to search engines
4 Identify relevant reports
5 Read and note contents, begins organising into themes
6 Using themes, develop report structure and undertake drafting
7 Iteratively review and refine draft
Comparative review of reported outcomes from interventions for children with hearing loss
medical sciences. This is even more the
case in assisting hearing-impaired children
with additional needs. Given the significant
impact of family on a child’s development,
a family-based practice also means
learning and support is more likely to be
sustained.
With regard to early development and
learning outcomes, evidence supports the
listening and spoken language approach
(auditory-verbal therapy and auditoryoral therapy) as an effective therapy.
Given that the vast majority of children with
hearing loss are born to parents who hear
and speak, this is an important finding.
– Deloitte Access Economics
These outcomes align with
parents’ aspirations for
their child, service provider
objectives, and the goal
of the NDIS “to optimise
the social and economic
independence of people
with disabilities”.
2
Comparative review of reported outcomes from interventions for children with hearing loss
1 Introduction
First Voice centres are located across
Australia and New Zealand. These
centres provide listening and spoken
language early childhood intervention
programs for children who are deaf
or hard of hearing and their families.
Services provided by First Voice centres
are family-based and delivered by highly
skilled multi-disciplinary teams of health
and education professionals. Services are
strongly focused on developing children’s
communication and social outcomes.
After three years of trials, the National
Disability Insurance Scheme (NDIS) is now
moving into full scheme implementation.
In August 2016, many aspects of eligibility,
access, services and funding are yet to be
determined. The overall aim of the NDIS
is to optimise the social and economic
independence of people with disabilities.
The scheme is based on ‘the insurance
principle’ and places a premium on the
principles of participant choice and control,
funding for reasonable and necessary
supports, evidence-based practice,
early intervention (including childhood
intervention) and value-for-money.
In June 2016 First Voice commissioned
Deloitte Access Economics to undertake
a literature review in regard to published
outcomes of different approaches to
developing communication in children
who are deaf or hard of hearing.
A subsequent social and cost benefit
analysis of the listening and spoken
language approach taken by First Voice
centres has also been commissioned.
The purpose of these studies is to
provide independent, reliable and
balanced information to governments,
government agencies (particularly the
NDIA) and parents/families regarding
3
1.1 First Voice
First Voice is the national voice for
member organisations whose primary
focus is the provision of listening and
spoken language therapy services in
Australia and New Zealand. Member
organisations include:
the published outcomes of listening
and language, and other, approaches to
developing communication in hearingimpaired children in the context of the stillevolving NDIS.
The Project brief called for a targeted
literature search focusing on:
•• Cora Barclay Centre, South Australia
•• Communication, learning, social
participation and later outcomes for
hearing-impaired children undertaking
listening and spoken language, and other,
early childhood intervention
•• Hear and Say, Queensland
•• Taralye, Victoria
•• Telethon Speech & Hearing,
Western Australia
•• Any significant factors influencing
outcomes such as a multi-disciplinary
team approach and family-based practice.
•• The Shepherd Centre, New South Wales
and Australian Capital Territory
•• The Hearing House, New Zealand.
The Literature Review also serves to inform
the subsequent social and cost benefit
analysis study.
Figure 1.1: First voice centres
1
Western Australia
Telethon Speech & Hearing
2
Queensland
Hear and Say
2
1
WA
New South Wales and
QLD
3 Australian Capital Territory
5
The Shepherd Centre
SA
3
NSW/ACT
4
4
Victoria
Taralye
5
South Australia
Cora Barclay Centre
6
New Zealand
The Hearing House
VIC
6
NZ
Comparative review of reported outcomes from interventions for children with hearing loss
First Voice champions the right of all deaf
people to listen and speak, and campaigns
for first rate early intervention services for
children who are deaf or hearing impaired.1
First Voice members provide familycentred, multi-disciplinary early childhood
intervention services to develop listening
and spoken language skills in deaf and
hearing-impaired infants and children.
This is a parent-based model of therapy,
where one or both parents are taught how
to teach their hearing-impaired child to
listen and speak. Parents are taught how
to create and use a listening and learning
environment in the home and elsewhere
so that their child can develop spoken
language using their ‘aided’ hearing.2
First Voice services and programs
are provided by multi-disciplinary
teams of health and education
professionals including:
•• listening and spoken language specialists
(internationally certified by the Alexander
Graham Bell Listening and Spoken
Language Academy)
•• speech pathologists
•• paediatric audiologists
•• teachers of the deaf
•• psychologists, family counsellors,
social workers and youth workers
•• early childhood educators
•• occupational therapists
•• paediatric ear nose and throat
surgeons, paediatricians, and other
relevant medical practitioners.
The First Voice model has a strong focus
on family-centred practice. This ensures
that the family is involved throughout the
intervention and that there is collaboration
between the multi-disciplinary team
and the family. Within the intervention
services, intensive counselling for the
parents is provided, along with education
sessions which aim to provide the
parents with information about the
intervention approach as well as other
topics of importance. Both intensive and
comprehensive services are provided to
families to ensure the child is supported in
their family environment.
A number of children who are hearing
impaired may also have additional
disabilities. In these cases First Voice will
work with other agencies and the child’s
family to ensure the child’s needs are
being met.
In addition to regular AVT sessions and
parent education, children and families
have access to family counselling and
support; a range of music, play and
language groups; on-site audiology
and cochlear implant support services;
supplementary speech pathology; and a
range of additional health and educational
specialists as and when required.
Hallmarks of First Voice
practice include:
1.Annual assessment of each
child’s receptive and expressive
vocabulary and speech
articulation to inform clinical case
management
2.Annual publication of consolidated
children’s outcomes data (over
700 children)
3.A strong commitment to research
and development.
In addition to their early childhood
intervention programs, different
First Voice members provide a range
of other services and programs;
key examples include:
1.Intensive transition to
school programs
2.Hearing implant services
3.Services to school-age children
4.Peer support programs
5.Community hearing screening and
audiology.
Home-based therapy is provided to
families who prefer this as well as therapy
via video-conferencing and tele-audiology,
for children and families living in regional,
rural and remote areas.
1. www.firstvoice.org.au
2. http://www.tsh.org.au/programs-services/hearing-impairment/auditory-verbal-therapy
4
Comparative review of reported outcomes from interventions for children with hearing loss
1.2 Childhood hearing loss in Australia
Although the exact number of babies
born each year in Australia with congenital
permanent childhood hearing impairment
(PCHI) is unknown, Australian Hearing
estimates that between nine and 12
children per 10,000 live births will be born
with moderate or greater hearing loss in
both ears. This equates to an incidence of
between 275 and 366 children in 2015.3 A
further 2.3 children per 1,000 will acquire
hearing impairment before the age of 17
(which necessitates hearing aids).4
Australia offers a universal neonatal
screening program which comprises a
simple, non-invasive hearing test, most
commonly offered within the first few days
of birth. About half of all children born with
a hearing loss have no known risk factors.
Known causes of congenital hearing loss
include genetics, maternal infections during
pregnancy such as rubella or syphilis, low
birth weight, hypoxia at the time of birth,
and certain medications during pregnancy
(World Health Organisation 2015).
A plethora of evidence (such as Kennedy
et al. 2006 and Yoshinaga-Itano 2004)
has demonstrated that detecting hearing
impairment early (ideally within the first six
months of life) and providing immediate
and effective interventions leads to better
outcomes for children. There are in fact a
number of different language development
pathways that children with hearing loss
can take, and evidence demonstrates than
when an efficacious intervention is offered
consistently during the first years of life,
this will help both families and children, as
well as decrease costs to society
(ECIA, 2016).
Programs for infants and children who are
deaf or hearing impaired typically work
in tandem with devices which amplify
sound and stimulate residual hearing.
Studies have shown that for children
with severe or profound hearing loss,
cochlear implantation before 12 months
of age brings about significantly more
developed language skills than delaying
the procedure (Colletti et al, 2011).
Australian Rod Saunders was the world’s
first cochlear implant recipient in 1978
with the first paediatric patients receiving
implants in 1985.5 Now more than 10,000
adults and children in Australia are using
cochlear implants and the requisite
surgery is considered a routine procedure,
performed in around two hours. A team of
health professionals, including audiologists
and medical specialists, assess the
suitability of hearing impaired candidates
for implantation and/or other devices
including hearing aids.
1.2.1 Current service delivery
framework
Through the combined efforts of all
levels of government, Australia is a world
leader in the planning and provision of
services and supports to children who
are deaf or hard of hearing. Current
arrangements include:
1
Early detection through universal
neonatal hearing screening
2
Prompt confirmation of diagnosis
and referral to Australian Hearing,
Australia’s expert provider of
paediatric audiology and hearing
aids for all Australian children up to
the age of 26 years
3
Fitting of free hearing aids within
8 to 12 weeks of diagnosis by
Australian Hearing
4
5
6
7
Cost-free access across Australia to
cochlear implants for children when
clinically appropriate
Timely and effective referral (in
most states/territories) to early
childhood intervention programs
for the development of
communication, generally within the
international/national guideline of less
than six months
Access throughout Australia to
high-quality, multi-disciplinary, familycentred listening and spoken language
early intervention providers
World leading research and research
collaborations through the Australian
Government; Hearing CRC; Macquarie
University Hearing Hub; other
universities; and leading service
providers including First Voice centres.
These arrangements are formed and
guided by the 2013 National Framework for
Neonatal Hearing Screening 6 and consistent
with the internationally acknowledged
Supplement to the American Academy
of Paediatrics, Joint Committee on Infant
Hearing (JCIH) 2007 Position Statement;
Principles and Guidelines for Early
Intervention after Confirmation that a Child
Is Deaf or Hard of Hearing.7
The approach adopted in Australia also
ensures that children who are deaf or
hard of hearing have the greatest possible
access to sound (including all the sounds
of the speech spectrum) in the shortest
possible time, thereby providing a platform
for the development of speech and
language through audition.
3. Rates applied to the Australian Bureau of Statistics (2015) estimate of
305,400 births in 2015.
6. http://www.health.gov.au/internet/main/publishing.nsf/Content/
neonatal-hearing-screening
4. https://www.hearing.com.au/causes-hearing-loss-australia/
7. http://pediatrics.aappublications.org/content/120/4/898
5. http://www.cochlear.com/wps/wcm/connect/au/about/company-history
5
Comparative review of reported outcomes from interventions for children with hearing loss
1.3 This project
First Voice commissioned Deloitte Access
Economics to undertake a comprehensive
literature review which will be used to
inform a subsequent cost-benefit analysis.
The purpose of the literature review (this
report) was to examine the effectiveness of
the First Voice multi-disciplinary approach
compared to other models of intervention
in achieving measurable outcomes.
The scope of this review was limited to
a focus on research findings regarding
the outcomes of interventions designed
to commence early in the life of children
diagnosed with hearing loss. It has not
considered other issues, such as access
or equity.
The review involved seven key steps:
1
Define research questions
2
Identify key search terms
3
Systematically apply search criteria to search engines
4
Identify relevant reports
5
Read and note contents, begins organising into themes
6
Using themes, develop report structure and undertake drafting
7
Iteratively review and refine draft
6
Comparative review of reported outcomes from interventions for children with hearing loss
In the first instance, research questions
were defined. These are shown in
Figure 1.2.
Figure 1.2: Research questions
Search terms were identified in
collaboration with First Voice. These are
listed in Table 1.1. The overall search
strategy was to concentrate on metaanalyses and systematic reviews to ensure
overall effectiveness of an intervention was
established. Then, individual trials within
the included studies were retrieved to
obtain data on specific outcomes
and interventions.
Table 1.2 presents an example of the
terms used in the literature search for
each of the interventions.
Table 1.1: Search terms for the review
•• What are the outcomes of
multidisciplinary early interventions
for children with hearing loss?
7
•• What are the costs of
providing instructions?
•• Parent-based model
•• Early intervention
•• Literature review
•• Are these interventions effective?
•• Hearing impairment
•• Cued speech
•• Speech reading
•• Deaf
•• Lip reading
•• Bilingual-bicultural
•• What is the comparator used in
the studies?
•• Hearing loss
•• Total communication
•• Multi-disciplinary
•• Hard of hearing
•• Auditory-verbal therapy
•• Interagency
•• What other interventions should
be considered?
•• Unilateral hearing loss
•• Oral-aural
•• Outcomes
•• Bilateral hearing loss
•• Native sign
•• Systematic review
•• What are the outcomes of
these models?
•• Sign only
•• Meta analysis
•• Auditory-oral.
Comparative review of reported outcomes from interventions for children with hearing loss
Table 1.2: Keywords for literature search
Total
communication
Cued
speech
Bilingualbicultural
Multidisciplinary
Family based
models
(Auditory-oral
therapy OR
oral-aural)
AND child AND
(hearing loss OR
hard of hearing
OR unilateral
hearing loss
OR bilateral
hearing loss)
Total
communication
AND child AND
(hearing loss OR
hard of hearing
OR unilateral
hearing loss
OR bilateral
hearing loss)
Cued speech
AND child AND
(hearing loss OR
hard of hearing
OR unilateral
hearing loss
OR bilateral
hearing loss)
(Bilingualbicultural OR
native sign OR
sign language)
AND child AND
(hearing loss OR
hard of hearing
OR unilateral
hearing loss
OR bilateral
hearing loss)
(multidisciplinary OR
interagency)
AND child AND
(hearing loss OR
hard of hearing
OR unilateral
hearing loss
OR bilateral
hearing loss)
(parent-based
OR family based
OR family
involvement)
AND child AND
(hearing loss OR
hard of hearing
OR unilateral
hearing loss
OR bilateral
hearing loss)
Auditory-verbal
therapy AND
outcomes
(Auditory-oral
therapy OR
oral-aural) AND
outcomes
Total
communication
AND outcomes
Cued speech
AND outcomes
(Bilingualbicultural OR
native sign OR
sign language)
AND outcomes
(multidisciplinary OR
interagency)
AND outcomes
(parent-based
OR family based
OR family
involvement)
AND outcomes
Auditory-verbal
therapy AND
(meta-analysis
OR systematic
review)
(Auditory-oral
therapy OR
oral-aural) AND
(meta-analysis
OR systematic
review)
Total
communication
AND (metaanalysis
OR systematic
review)
Cued speech
AND (metaanalysis OR
systematic
review)
(Bilingualbicultural OR
native sign OR
sign language)
AND (metaanalysis OR
systematic
review)
(multidisciplinary OR
interagency)
AND (metaanalysis OR
systematic
review)
(parent-based
OR family based
OR family
involvement)
AND (metaanalysis OR
systematic
review)
AVT
AOT
Auditory-verbal
therapy AND
child AND
(hearing loss OR
hard of hearing
OR unilateral
hearing loss
OR bilateral
hearing loss)
A targeted search of the following
references was conducted:
•• Pubmed, Google Scholar and the
Cochrane Library (for published papers
using search terms listed in Table 1.1)
•• Papers provided, or suggested by
First Voice; and
•• Past work done by Deloitte Access
Economics related to hearing impairment
such as Listen Hear: The Economic
Impact and Cost of Hearing Loss
in Australia.
Relevant works were identified, read and
pertinent information organised into
themes. The interventions of interest were
compared and contrasted in relation to
the main research outcomes and findings
drawn together into a complete review.
1.4 Report structure
The remainder of this report is
structured as follows:
•• Section 2 – Pathways for children
with hearing loss
•• Section 3 – Common characteristics
of early interventions
•• Section 4 – Overview of findings
•• References.
8
Comparative review of reported outcomes from interventions for children with hearing loss
2 Pathways for children with
hearing loss
In essence, there are four main language
development pathways that infants with
hearing impairment can follow.
Listening and spoken language
therapies (which includes auditoryverbal and auditory-oral therapies)
Total communication approaches
Therapies with sign language
components
Cued speech.
However, the pathways have some
overlapping characteristics and may be
used in conjunction with each other. For
example, total communication embraces a
variety of communication methods which
may also be used in alternate approaches.
One such method is signed English, which
is also a component of signed language
focused therapies. Additionally, a multidisciplinary approach may be adopted
by each pathway and this has been
discussed separately.
These pathways may also include the use
of aids to enable the child to access sound.
For the listening and spoken language
pathway, a critical deature is the optimal
use of aids to provide the best possible
access to sound. These aids include:
•• Hearing aids
•• Cochlear implants (also middle ear and
bone conduction implants)
•• Brain stem implants
•• Assistive mechanisms.
9
Family involvement and collaboration is
desirable across all pathways.
There are two broad cultural perspectives
on interventions for children with hearing
impairment. Access Economics (2006)
described these as the medical-disability
model and cultural-linguistic model.
Proponents of the first model, particularly
hearing parents whose children are born
deaf, often identify with hearing culture.
Parents seek to help their child integrate
into the hearing community and wish for
their child to have similar life opportunities
as their hearing counterparts.
By comparison, under the culturallinguistic model, deafness is viewed with
a sense of pride and as a unique cultural
linguistic experience. Members of this
community commonly use sign language
to communicate and may not pursue
treatments to improve their speaking or
hearing ability. Individuals identity as a deaf
person, and do not view the hearing loss as
something requiring a clinical intervention.
The remainder of this section provides
detail about each of the pathways
listed above.
Comparative review of reported outcomes from interventions for children with hearing loss
10
Comparative review of reported outcomes from interventions for children with hearing loss
2.1 Listening and spoken language
Therapies to improve listening and
speaking skills in hearing-impaired children
include AVT and auditory-oral therapy
(AOT). The aim of this pathway is for the
child to learn spoken language. As a result
of this, aids and modifications are essential
to the listening and spoken language
pathway. The First Voice model falls into the
listening and spoken language category as
a result of its use of AVT and AOT.
6.Guide and coach parents to help their
child integrate listening and spoken
language into all aspects of the child’s life
2.1.1 Auditory-verbal therapy (AVT)
AVT is an intensive early intervention
approach which aims to teach children
with hearing loss how to listen, understand
spoken language and speak. This is done in
conjunction with amplifying their residual
hearing with aids and implants. AVT may or
may not be a multi-disciplinary approach
(Australian Hearing, 2005).
9.Administer ongoing formal and
informal diagnostic assessments to
develop individualised AVT plans, to
monitor progress and to evaluate the
effectiveness of the plans for the child
and family
Principles of AVT are set out by the AG
Bell Academy for Listening and Spoken
Language.8 These are:
1.Promote early diagnosis of hearing loss
in newborns, infants, toddlers, and
young children, followed by immediate
audiologic9 management and AVT
2.Recommend immediate assessment
and use of appropriate, state-of-the-art
hearing technology to obtain maximum
benefits of auditory stimulation
3.Guide and coach parents to help their
child use hearing as the primary sensory
modality in developing listening and
spoken language
4.Guide and coach parents to become
the primary facilitators of their
child’s listening and spoken language
development through active consistent
participation in individualised AVT
5.Guide and coach parents to create
environments that support listening
for the acquisition of spoken language
throughout the child’s daily activities
7.Guide and coach parents to use
natural developmental patterns of
audition, speech, language, cognition,
and communication
8.Guide and coach parents to help their
child self-monitor spoken language
through listening.
10.Promote education in regular schools
with peers who have typical hearing
and with appropriate services from
early childhood onwards.
This method seeks to assist children
to participate more fully in the hearing
world, including mainstream schools,
and in communicating with their parents,
recognising that nine out of ten babies
with a hearing impairment are born to
hearing parents.10
2.1.2 Auditory oral therapy (AOT)
AOT aims to teach deaf children to speak
and lip read, with the help of aids and
modifications such as cochlear implants.
This method focuses on speaking and
sound production unlike the AVT approach
which places greater importance on
listening (Gravel et al. 2003). Unlike AVT, this
method also might use lip reading, facial
expressions and natural gestures, but does
not involve signed language. This pathway
seeks to enable individuals with hearing
impairment to function independently
in the hearing world, including attending
mainstream schools and engaging in social
interaction opportunities similar to those of
their hearing peers.
8. http://www.agbell.org/AcademyDocument.aspx?id=563
9. Audiologic infers relating to audiology, the study of hearing impairment
and care of individuals with a hearing disorder
11
2.2 Total communication
Total communication comprises a
variety of communication methods
including speech, lip-reading, listening,
formal signing and finger spelling.
Simultaneous communication is a form
of total communication.
Lip
reading
Formal
signing
Speech
Listening
Total
communication
Finger
spelling
These methods may be used alone, or
in combination with each other and
alongside hearing aids and/or cochlear
implants to amplify residual hearing
(Australian Hearing, 2005). Children using
total communication may use more sign
language, more spoken language, or a
similar amount of each (Fletcher 2013).
The signed system used in a Total
Communication method is signed English
as Auslan has a considerably different
grammatical structure.
10. http://www.aussiedeafkids.org.au/you-and-your-deaf-child--a-guide-forfathers.html
Comparative review of reported outcomes from interventions for children with hearing loss
The purpose of this approach is to enable
children who are deaf or hearing impaired
to communicate through all available
modalities and to make interactions
flexible, whereby the individual can adopt
whichever mode of communication is most
appropriate for the situation.
Some parents elect this approach for their
child to provide them with an opportunity
to assume a cultural identity as part of
the deaf community (Hyde and Power,
2005) whilst aiding their integration into a
hearing society. Parents need to learn sign
language and in the home environment
are encouraged to use sign language in
conjunction with clear, visible speech.
The child then uses any hearing capability,
signs and lip reading for communication.
In practice, it is difficult to sign and
speak simultaneously and parts of
either form of communication may be
left out, thus making communication
more cumbersome.
2.3 Sign language
Auslan, or Australian sign language, is the
primary language of the Australian deaf
community. Auslan is a unique language
with a distinct grammatical structure. Often
children of deaf parents learn Auslan as
their first language and, naturally, parents
choosing this approach for their infant are
required to learn this sign language.
2.4 Cued speech
This pathway uses hand shapes, hand
positions and lip reading to communicate.
The hand shapes are specific to cued
speech and represent different consonants
and vowels are distinguished by placement
of the hand (Gravel et al. 2013). The signed
movements are different to those used
in Auslan.
In 1991 the Australian government
recognised Auslan as the principal means
of communication within the Australian
deaf community and an indigenous
Australian language (Dawkins 1991).
Sometimes this intervention is referred
to as a total communication pathway
due to the various techniques used in
the intervention, while other times this
pathway might be grouped with AVT
and AOT due to the focus on language
development. For this report’s purposes
it is treated separately as literature was
retrieved which explicitly referred to the
cued speech pathway.
For deaf people who communicate using
Auslan, English is taught as a second
language through reading, writing or sign
systems (Australian Hearing, 2005). Signed
English is rarely used by deaf adults.
Schools may use signed English to help
a child’s understanding of the English
language whereby the signing plus finger
spelling exactly replicates what is spoken.
These interventions are referred to as
bilingual-bicultural programs.
It should be noted that cued speech is
rarely used in isolation and is normally
used with other pathways. Cued speech is
also rarely used in Australia (Aussie Deaf
Kids, 2015).
12
Comparative review of reported outcomes from interventions for children with hearing loss
2.5 Summary
Table 2.1 provides a summary of the main characteristics of each approach. Each of the
pathways may also involve the use of devices such as hearing aids or cochlear implants.
In some pathways, such as AVT and AOT, the use of devices is a critical component of the
pathway for the child.
Table 2.1: Summary of defining characteristics of different pathways
Auditory-verbal
therapy
Lip-reading
Facial expression
Natural gestures
Finger spelling
Signed English/hand gestures
Auslan (or equivalent) as primary
language and spoken English (or
equivalent) second language
Speech and sound production
Hearing aids and/or implants
13
Auditory-oral
therapy
Total
communication
Sign
language
Cued
speech
Comparative review of reported outcomes from interventions for children with hearing loss
3 Common characteristics of
successful interventions for
hearing impaired children
This section discusses components of
interventions that have been found to
result in positive outcomes for children.
These characteristics may be factored into
any pathway for a child with hearing loss.
3.1 Multi-disciplinary team
A multi-disciplinary approach is where
professionals from a variety of fields work
together to provide services to a child with
hearing loss. The professionals who are
involved in this process are referred to as
a multi-disciplinary team. The specialists
who may be included in a multi-disciplinary
team for children who are deaf or hearing
impaired are listed in Section 1.1.
A multi-disciplinary approach
acknowledges that children who have
hearing loss may potentially have a range
of comorbidities along with their hearing
loss such as cognitive impairment plus
communication challenges at school and
within the family unit.
Each pathway included in this section
may be provided in a multi-disciplinary
setting and therefore multi-disciplinary is
not viewed as a separate pathway, or as
a mutually exclusive intervention. As an
example, most interventions include family
counselling and can therefore be deemed
multi-disciplinary.
Sydney Children’s Hospital, Randwick,
adopts a multi-disciplinary approach in its
Hearing Support Service clinic for children
and babies who have a recent diagnosis
of a permanent hearing loss, as does the
Deafness Centre within The Children’s
Hospital at Westmead.
3.2 Family-based practices
Early intervention with family involvement
is crucial for a child’s development.
Early intervention has found to be more
successful when family is involved in the
intervention and at the beginning of the
intervention so that a solid foundation for
the child is developed and can then be
maintained.
This approach recognises that family is the
primary influencer on children’s learning
and development. A child may undergo
an early intervention program, but this
program may only consist of a child having
exposure to a professional for a few hours
each week. The family of a child therefore
plays a crucial role in ensuring that what
a child learns in their early intervention
program is implemented in their day
to day lives. To do this, the family must
have adequate knowledge of the early
intervention objectives and teachings
so that they may guide and support
their child.
Family-based practice involves the
collaboration between the family of the
child and the professionals involved in
delivering the intervention. This may
involve the family attending therapy
sessions with their child, and/or having
a separate session with the professional
working with their child to discuss the
early intervention.
Early Childhood Intervention Australia
(ECIA) is a government funded organisation
which represents professionals and
organisations that provide early
intervention services. ECIA created a
Best Practice Guide for early childhood
intervention practitioners on how to
become more inclusive in their practices.
This publication arose from recent findings
that showed inclusive interventions have
positive outcomes for children. At the core
of this guide is family-based practice. Many
elements of the guide focus on discussing
family matters that may impact the child,
and how to communicate with the family
about the child’s needs (ECIA, 2014).
14
Comparative review of reported outcomes from interventions for children with hearing loss
4 Overview of findings
The outcomes most commonly reported
in the retrieved papers, and therefore the
focus of this review, were:
•• Early development outcomes
(speech, language)
•• Learning outcomes (school and
post-secondary)
•• Social and wellbeing outcomes.
Information or study gaps were identified.
Although articles provided an indication of
outcomes, evidence was limited and
no well-controlled prospective studies
were found.
Across the broad range of articles
retrieved, some common shortfalls
were observed, namely:
•• Small sample sizes
•• Reliance on self-reported data
•• No comparison group
•• Retrospective studies.
Additionally, given the widespread use
of cochlear implants and/or hearing
aids, most papers studied the impact of
different therapies in combination with
these devices. Whilst this reflects current
practice, it makes attributing outcomes
exclusively to the pathways of interest
(outlined in Section 2) more uncertain
because the presence of implants and/
or aids confounds analysis of other
interventions in isolation.
Systematic reviews and meta analyses
of interventions for children who are
deaf or hearing impaired were desired
15
however a number of those retrieved
concluded there was insufficient or
minimal evidence to assure the
outcomes of AVT. A similar challenge
existed for the other interventions.
These shortcomings compromise the
robustness of findings and the ability
to extrapolate them to the Australian
context. To take these factors into account,
findings have been presented along with
an indicator of the strength of the finding.
This indicator is based on the rankings
that Eriks-Brophy (2004) and Dornan et al.
(2008) adopted in their literature review
which were derived from the strength of
the article’s methodology. The strength of
the literature has been assigned one of the
following levels:
•• Promising practice: shows some
research on outcomes and is nonexperimental in design. Includes articles
which use questionnaires, case studies
or group judgements
•• Evidence informed: evidence of effect
with a strong research design, defined
as experimental (randomised) or quasi
experimental (match control groups)
•• Evidence based: evidence of effect
with a strong research design and
sustained effect at least one year
beyond treatment.
High level findings are presented in
Table 4.1, along with the strength of the
evidence – noting that no ‘evidence based’
information was found, as per the highest
tier above. Further detail is provided in the
sections that follow.
Comparative review of reported outcomes from interventions for children with hearing loss
Table 4.1: Summary of defining characteristics of different pathways
Intervention
Outcomes
Early development
Learning and later outcomes
Social and wellbeing outcomes
Auditory-verbal
Auditory-oral
Total communication
Cued speech
Sign language
Multi-disciplinary
Strength of evidence
Promising practice
Outcomes
Evidence informed
Evidence based
Positive impact
Neutral or mixed feelings
No information
16
Comparative review of reported outcomes from interventions for children with hearing loss
4.1 Variables that impact outcomes
It is noted that a number of factors impact
the outcomes for children with hearing
impairment. A literature review performed
by the Centre for Allied Health Evidence
(2007) appraised all available evidence
concerning variables that influence
outcomes for children who have hearing
loss. The study identified the following
parameters that influence outcomes:
•• Age at onset of hearing loss
•• Age at implantation
•• Duration of hearing loss
•• Age at detection of hearing loss
•• Educational factors (whether the
child is in mainstream education or
special education).
17
The study also highlighted a number
of variables that potentially influence
outcomes. The study describes these
variables as ‘potentially’ influencing
outcomes because the articles reviewed
either had conflicting results, or there
was a limited research on the variable. A
selection of the variables that potentially
influence outcomes are:
•• Socioeconomic status
•• Gender
•• Parental communication
•• Family structure
•• Comorbidities
•• Cause of hearing loss.
Outcomes from the prospective Australian
Longitudinal Outcomes of Children with
Hearing Impairment study concurred with
these findings. Ching (2015) reported that
at three years of age study participants
who had received earlier implantation
displayed superior language outcomes. By
five years of age strong, clear evidence was
found that earlier age at intervention was
associated with better outcomes such as
better language outcomes. Other factors
associated with higher language scores
were higher maternal education, use of
an oral mode of communication, and the
absence of additional disabilities.
Comparative review of reported outcomes from interventions for children with hearing loss
4.2 Early development outcomes
Outcomes within this section focus on
communication outcomes of children who
are in preschool or prior to starting primary
school (typically children under the age
of five). The section is divided into studies
that reported findings which were positive,
neutral or mixed and negative.
As noted earlier, literature focused
on interventions for children with
hearing loss suffers from a number of
methodological issues. However, some
interventions appear to be better than
others with respect to the outcomes of
interest. Whilst the available literature
revealed mixed results, AVT and AOT were
mostly shown to have a greater impact
on language and speech outcomes than
total communication programs and
bilingual-bicultural programs. When total
communication programs and bilingualbicultural programs were compared,
outcomes were superior in the total
communication programs.
4.2.1 Positive findings
A systematic review of the literature
undertaken by Kaipa and Danser (2016)
found that AVT had a positive impact on
speech perception abilities. The review
found two studies (Sahli and Belgin 2011
and Fairgray et al. 2010) which reported a
positive change in the speech perception
abilities of children who were receiving AVT.
Both studies found that speech perception
scores of children post AVT were higher
than before AVT. However, Kaipa and
Danser (2016) criticised these studies for
not including a control group.
Another study that looked at the speech
and language outcomes of children who
underwent AVT was Diller et al. (2001).
At the end of this study 50.5% of children
in the sample had hearing level similar to
children with normal hearing and 48.4%
had level of speech and language similar to
children with normal hearing. Diller et al.
(2001) had 103 children in their study who
were all under the age of 24 months. This
study tested children in three different time
periods using questionnaires.
Eriks-Brophy (2004) and Dornan et al.
(2008) performed a review of all AVT
literature. These reviews found that
children who were enrolled in AVT were
able to make substantial progress in the
development of speech, language, and
reading skills. The first of these published
articles, Eriks-Brophy (2004) found seven
appropriate articles that report on AVT
outcomes. The author concluded that the
available evidence supports AVT and the
potential positive outcomes for speech,
language and reading. However, there were
a number of issues with available evidence.
Mainly that evidence was retrospective,
based on small sample sizes and unable
to be compared due to a number of
different outcomes being measured in
the literature. As a result, Eriks-Brophy
called for future research to be more
collaborative and sophisticated.
Dornan et al. (2008) came to a similar
conclusion as Eriks-Brophy (2004)
and found that existing literature
demonstrated the potential for speech
and language development with AVT, but
the articles suffered from methodological
issues. Dornan et al. (2008) also noted
that children receiving other forms of
interventions also have positive outcomes,
but the benefits are greater for children in
oral programs than programs that include
sign language.
Other than the rate of language
development, Dornan et al. (2010) also
looked at speech and language outcomes,
reading and mathematical ability and
self-esteem of children. In all areas, the
Dornan et al. (2010) study found that
children who underwent AVT did not have
statistically significant different results
from hearing children in speech, language
and self-esteem.
A literature review conducted by Econtext
(2011) found a variety of articles that
discuss the outcomes of AVT. One such
study by the University of Michigan
(Heavner K et al 2006) which found that
speech and language outcomes for AVT
in children with cochlear implants were
superior to those compared to total
communication and oral communication
methods. According to Econtext (2011) the
University of Michigan was so convinced
by these results, specialists there began
to recommend AVT to parents over other
interventions.
Positive AVT outcomes were also reported
in another study by Percy-Smith et al.
(2010). This study found that children
who used auditory-verbal as a mode
of communication were more likely to
achieve a high score on a phonological
test compared to children who used
auditory-oral or total communication
modes of communication. The authors
also found that the children in the
auditory-verbal group performed better
than those children who were exposed
to aural-oral or total communication
in terms of language abilities. The study
included 155 children and all children had
cochlear implants. The average age that
children underwent cochlear implantation
was 19.6 months. To analyse speech
production, the authors had the children
read out different words. The speech of the
children was then assessed for phoneme11
accuracy of vowels and consonants. To
measure language ability the authors
used the Reynell Developmental Language
Scales, a tool used by therapists to
study a child’s speech and language,
and also a Danish vocabulary test called
‘vibord materilet’. One shortcoming of
the Percy‑Smith et al. (2010) study was
the absence of a comparator group
with normal hearing, as highlighted by
Fletcher (2013).
18
Comparative review of reported outcomes from interventions for children with hearing loss
19
Comparative review of reported outcomes from interventions for children with hearing loss
Another study by Dettman et al. (2013)
compared children who used auditoryverbal, auditory-oral and bilingualbicultural communication. The results
of this study found that children who
used auditory-verbal and auditoryoral communication had better speech
perception and language outcomes
than those children who used bilingualbicultural communication. The rate of
language growth for the three groups was
1.1, 1.2 and 0.7 for auditory-verbal, auraloral and bilingual-bicultural respectively
(1.0 is defined as the normal rate for all
children). Results for a speech perception
test showed that mean phoneme score
for the auditory-verbal, aural-oral and
bilingual-bicultural groups were 81%,
74% and 57% respectively. These results
indicate that in terms of language
and speech perception outcomes,
children who use auditory-verbal
modes of communication and aural-oral
modes of communication outperformed
children who use bilingual-bicultural modes
of communication.
The Dettman (2013) study included eight
children in the auditory-verbal group,
23 in the aural-oral and eight in the
bilingual-bicultural group. The authors
used the Peabody Picture Vocabulary Test
to assess language outcomes of children.
To assess speech perception outcomes
the authors had the children repeat words
from a consonant-nucleus-consonant
word list and sentences from the BenchKowal-Bamford Sentence Test. One
criticism of this study identified by Fletcher
(2013) was that the mean age of the three
groups differed. The mean ages of the
auditory-verbal, aural-oral and bilingualbicultural groups were 6.2, 4.9 and 4.9
respectively. Fletcher (2013) emphasised
that age will impact the results as older
children will have more developed skills.
A study by Archbold et al. (2000) also
compared outcomes of children who
underwent oral communication
approaches to those who underwent total
communication approaches with a focus
on signed language. This study found
that children in the oral communication
setting outperformed those that used total
communication approaches in terms of
speech intelligibility. This study analysed
children’s outcomes at three, four and five
years post implantation and comprised of
46 children. An issue with this study was
the small sample size of cohorts as time
progressed. Although the sample size
was initially 46, some results are based on
sample sizes as small as seven.
A more recent review by Sarant (2016)
also analysed the outcomes of children
in an oral communication education
setting compared to those in an oral
plus sign setting. Sarant found that
children in an oral setting had significantly
better speech perception and speech
production outcomes than children in an
oral and sign setting.
A study by Wiefferink et al. (2008) looked
at two groups of deaf children, one group
which was educated in a bilingualbicultural environment and another
which was educated in a simultaneous
communication environment (a form of
total communication). The study found
that the group of children who were
exposed to simultaneous communication
performed better than the group exposed
to bilingual communication in terms of
receptive and expressive spoken language
development. The study also found
that the children in the simultaneous
communication group who received
cochlear implants before the age of 18
months had similar scores to hearing
children of the same age.
All children in the study had cochlear
implants and differed in age of implantation
(the range was 9 to 27 months). In the
group of children who were exposed
to bilingual education, there were six
children who spoke Dutch and knew Sign
Language of the Netherlands (SLN). In the
group of children who were exposed to
simultaneous communication there were
12 children. These children spoke Dutch
but also used some supported signs.
Children in the study were assessed once
prior to implantation and then again 6, 12,
24 and 36 months after implantation. The
Categories of Auditory Performance test
was used to assess auditory perception,
the Speech Intelligibility Rating Scale
and the Meaningful Use of Speech
Scale was used to measure speech
intelligibility. The Dutch version of the
Reynell Developmental Language Scale
and the Schlichting Scale was used to
assess spoken language and spontaneous
language was assessed through the use
of conversations with adults and analysis
through Computerised Language Analysis
tools. A methodological problem identified
with this study was that the children in the
simultaneous communication group
had on average been implanted earlier
than the bilingual group given that earlier
implantation is linked to better outcomes.
A longitudinal study by Cochard et al. (2003)
analysed the impact cued speech had on
speech outcomes for children. This study
found that children who were exposed
to cued speech had superior speech
outcomes compared to those exposed to
sign language or to an oral setting. Results
of this analysis found that cued speech
users outperformed the other two groups
when perception of words in open and
closed lists was assessed. Similarly, children
who were exposed to cued speech also
11. A phoneme, in linguistics, is the smallest unit of speech distinguishing one word from another. https://www.britannica.com/topic/phoneme
20
Comparative review of reported outcomes from interventions for children with hearing loss
outperformed the other two groups in
terms of speech intelligibility. This study
also looked at family involvement and
found that children whose family attended
cued speech sessions performed better
than those that did not. For one and
three years post cochlear implantation,
cued speech had an advantage over the
other two settings, but lost this advantage
after five years. This study also looked at
sentences in open sets where the cued
speech group was again superior to the
other groups.
The Cochard et al. (2003) study analysed
three groups of children who were exposed
to different modes of communication
prior to cochlear implantation. One group
was exposed to an oral setting, the
second group to a signed French setting,
and the third to a cued speech setting,
in total there were 53 children. The groups
were assessed one, three and five years
after receiving their cochlear implants.
The children were tested regarding
auditory discrimination, speech
comprehension, spoken intelligibility,
and language development.
Other studies that looked at cued speech
also found positive language development
and language processing outcomes.
Studies such as Kipila (1985), Anthony et
al. (1991) and Metzger (1994) all found that
deaf children with hearing parents who
used cued speech had language outcomes
similar to hearing children. However, the
Kipila (1985) study only looked at the
outcomes of one child and so did the
Anthony et al. (1991) study. The Metzger
study (1994) study was a follow up study
to the Kipila study (1985) and therefore
had the same issue of only looking at the
outcomes of one child. Therefore, any
conclusions drawn from these articles
should be treated with caution due to the
small sample sizes.
21
4.2.2 Neutral or mixed findings
Another outcome that Kaipa and Danser
(2016) included in their systematic review
was the impact of AVT on the rate of
language development. The authors
found four studies that showed AVT had
a positive impact on the rate of language
development, but also found two studies
which found that AVT had a negligible
impact on other outcomes of interest.
The authors calculated the mean rate of
language development for participants
before and after AVT and then
compared rates, taking into account the
participant’s age, reading level and length
of participation in AVT. This review is
inconsistent with three studies (Hogan et
al. 2008, Hogan et al. 2010 and Rhoades
and Chisholm 2000) which reported
considerable growth between the before
and after language development score
following AVT. These studies indicated
that AVT had a positive impact on rate of
language development.
An important longitudinal study by Dornan
et al. (Dornan et al. 2007, 2009 and 2010)
was reviewed by Kaipa and Danser (2016).
The Dornan et al. studies followed children
with hearing impairment who were part
of a multi-disciplinary family-centred
AVT. The study gave rise to three articles;
an analysis of outcomes before and after
a 9–month period of AVT, before and after
a 21-month period of AVT and then before
and after a 50-month period. The first of
these studies (Dornan et al. 2007) found
that there was considerable language
growth following AVT, while the other two
studies (Dornan et al. 2009 and Dornan et
al. 2010) showed negligible growth.
Despite these positive initial findings,
Kaipa and Danser (2016) postulated
methodological issues with the Dornan et
al. longitudinal study. For instance, when
Kaipa and Danser investigated the results
from the Dornan et al. articles, they found
that the participants had a high average
rate of language development to begin with
when compared to the other studies. The
authors suggested that Dornan et al. were
too selective in the inclusion of participants
in their study.
4.2.3 Negative findings
As was reported earlier, studies by
Dettman et al. (2013), Wiefferink et
al. (2008), Percy-Smith et al. (2010)
and Cochard et al. (2003) compared
interventions to each other. The first
study by Dettman et al. (2013) found that
children who were enrolled in bilingualbicultural programs had inferior outcomes
to those of children who were enrolled
in AVT or AOT. A study by Percy-Smith et
al. (2010) compared children who used
auditory-oral, auditory-verbal and total
communication modes of communication.
This study found that children who
used total communication modes of
communication had inferior outcomes
to those who used auditory-verbal or
auditory-oral modes of communication.
Wiefferink et al. (2008) compared
outcomes from children educated in
bilingual-bicultural programs to those of
children in simultaneous communication
outcomes. The study found that bilingualbicultural was inferior to simultaneous
communication. Lastly, Cochard et al.
(2003) found that outcomes for children
who were exposed to sign language or to
an oral setting were inferior to those who
were exposed to cued speech.
Comparative review of reported outcomes from interventions for children with hearing loss
4.3.1 Positive findings
A study by Robertson and Flexer (1993)
analysed the reading outcomes of children
who had undergone AVT. The authors
found that 30 out of the 37 children
included in the study scored at the 50th
percentile or higher on reading tests
when compared to children with normal
hearing. For this study, the authors had the
parents of children who had undergone
AVT complete a survey. There were 37
responses with children ranging from
6-19 years. Included in the survey were a
number of questions about their child’s
reading progress. However, these study
results are compromised by a small
sample, large variation in ages of the
studied children and self-selected data.
Another longitudinal study by Goldberg
and Flexer (1993 and 2001) found positive
outcomes for AVT graduates in terms of
educational and employment attainment.
Goldberg and Flexer conducted a survey
of Canadian and American AVT graduates
in 1993 and in 2001. The 2001 responses
found that the majority of people who
had undergone AVT felt like they were
integrated into the hearing world and
had graduated from high school. The
1993 survey had 157 usable responses
and the 2001 survey had 114 usable
responses. Outcomes that were studied
in these articles included employment
and education history. The main interest
in educational history was the degree of
mainstreaming, which the authors define
as a deaf person being fully integrated
into a hearing school. The 2001 survey
responses reported that 84% of AVT
graduates were fully mainstreamed in
middle and junior high school while 91%
were fully mainstreamed in their senior
high school years. Another finding was that
most respondents had graduated from
high school, all but three had reported
graduating. Of those that did graduate,
78% were attending mainstream colleges
or universities. This study is one of the few
identified which reported employment
outcomes. Goldberg and Flexer (2001)
reported that 44% of AVT graduates
reported being students or homemakers
however, 41% of recorded having a
personal income $20,000 per annum or
above in 2000.
Another study by Tobey et al. (2004) looked
at 131 deaf children aged eight to nine
years who had cochlear implants. This
study found that children who attended
AOT programs had better speech
intelligibility when compared to children
who attended total communication
programs. The AOT group of children and
the total communication group achieved
average speech intelligibility scores of
70.8% and 39.4% respectively.
Within the study, the two groups of
children were also broken down into the
three classroom settings that the children
in the group were exposed to and then
the results were compared for each group.
The three classroom settings
were referred to as special, partial and
full. Special referred to education settings
that had exclusive enrolment in a deaf
classroom, partial referred to part-time
enrolment in classes with children
without hearing loss, and full mainstream
referred to children who were exclusively
enrolled in classes with children without
hearing loss. When speech intelligibility
was analysed in the children three years
after cochlear implantation, the AOT
group on average, outperformed the total
communication group, regardless of the
educational setting. When educational
settings were compared, the children in
the full mainstream group on average
outperformed the other groups.
Chart 4.1 presents speech intelligibility
results of the children three years after
cochlear implantation.
Chart 4.1: Speech intelligibility of children three years after cochlear implantation
Current Classroom Placement
100
80
Intelligibility %
4.3 Learning and later outcomes
This section focuses on studies
which involved school aged children.
The reviewed studies reported that
children enrolled in auditory-oral or
auditory-verbal programs outperformed
those who were enrolled in total
communication programs.
60
40
20
0
Special
Partial
Total Comunication
Full
Special
Partial
Full
Auditory-Oral
Source: Tobey et al (2004)
22
Comparative review of reported outcomes from interventions for children with hearing loss
To measure intelligibility, the authors of
the Tobey et al (2004) study found words
that were used to predict intelligibility in
deaf children and put these in a sentence
which the children repeated. Three judges
listened to the children and scored their
intelligibility. Results from the three judges
were then averaged to give a score for each
child. Children in the study were grouped
into either attended AOT (74 children)
or total communication programs (55
children). However, Tobey et al. used
different definitions than those presented
in the earlier chapter. The AOT designation
was used for children who did not use sign
language in their mode of communication.
This group therefore included children who
participated in cued speech, auditoryoral, and auditory-verbal programs.
While the total communication group
included children who participated in
programs that emphasised use of sign
language. This implies that the results
from this study are a comparison between
signed language groups and cued
speech, auditory-oral and auditoryverbal programs.
A study by Geers and Moog (1992) looked
at children aged 16 and 17 years who were
enrolled in either a total communication
program or an auditory-oral program.
In all the tests, the auditory-oral group
of children out performed the total
communication group. There were
227 children in the study and the oral
communication skills of those in later
adolescence were investigated. The study
aimed to look at the impact the programs
had on speech perception and production
skills. However, a number of limitations
of this study were highlighted. The two
groups had different socioeconomic
status (the total communication group
had lower median income than the
auditory-oral group) and the two groups
had different educational settings (the total
communication group attended residential
schools for the deaf while the auditoryoral group mainly attended mainstream
educational centres).
23
A study by Bouton et al. (2011) focused
on cochlear implantation and compared
groups of children who have been
exposed to cued speech before and after
implantation to groups of children who had
not been exposed to cued speech. The
analysis found that the group of children
who had been exposed to cued speech
had greater phonemic awareness plus high
reading task accuracy. The children were
asked to perform phonemic awareness
tasks and reading tasks.
Torres et al. (2008) also conducted research
related to the reading ability of children
who had been exposed to cued speech.
This study found that students in the
cued speech group were skilled readers
compared to standardised norms for their
age groups. The study also found that the
children who had exposure to cued speech
had age-appropriate linguistic competence.
The small sample size (of four children) was
aged between 12-13 years and had been
exposed to cued speech from an early age
(between 8 and 16 months). There were
two other groups of children who served as
controls and the children in these groups
had normal hearing. The representative
nature of these findings to the hearing
impaired population is limited owing to the
small sample size.
Aparicio et al. (2012) studied 45 adults,
some of which were exposed to cued
speech and auditory-oral settings
and others who were exposed only to
auditory-oral settings. The results of this
study found that the participants who were
exposed to cued speech outperformed
hearing participants in reading skills. Of
the 45 participants, 30 were exposed to
auditory-oral French of which 15 were also
exposed to cued French. The remaining
15 participants had normal hearing. All
participants underwent a speechreading
test which involved participants
viewing sentences being read and then
undergoing tests that assessed the level of
understanding of the participant.
Hermans et al. (2008) studied 87 deaf
children from the Netherlands to appraise
a relationship between reading skills and
signing skills. The children knew SLN or
Sign Supported Dutch (SSD). A positive
correlation between vocabulary scores for
signing and written skills was identified.
Children’s reading skills were assessed
using a reading vocabulary test and a
written story comprehension test. Sign
language skills were also assessed using
a receptive vocabulary test and a story
comprehension test
An earlier study by Strong and Prinz
(1997) analysed the relationship between
American Sign Language (ASL) skills
and English literacy skills. A statistically
significant relationship between ASL skill
and English literacy was found with English
literacy performance increasing with ASL
capability. There were 160 deaf children
included in the study who were aged
between eight and 15 years. ASL skills were
assessed using an ASL test developed
by Strong and Prinz. The test measured
ASL production and comprehension. To
assess English literacy the authors used
subtests from the Woodcock-Johnson
Psychoeducational Test Battery and the
Test of Written Language.
4.3.2 Neutral or mixed findings
A longitudinal study by Hayes et al. (2009)
looked at deaf children who had cochlear
implants and used auditory-oral as their
mode of communication compared to
hearing children. The study found that the
children with cochlear implants performed
below the average of the hearing group.
However, the study found that the children
with cochlear implants had a faster rate
of growth in receptive vocabulary gains
compared to the expected age-appropriate
level of growth. As a result of this finding,
the authors predicted that although there
was a sizeable gap between children with
cochlear implants and hearing children, the
gap would eventually close and the children
with hearing impairment would assume
Comparative review of reported outcomes from interventions for children with hearing loss
age-appropriate level of vocabulary skills.
There were 65 children included in the
study and they were given the Peabody
Picture Vocabulary Test annually. The
results of the tests were standardised
and compared to results from normal
hearing children.
communication programs had on
average better consonant-production
accuracy and greater rates of improvement
than the total communication cohort.
There was however no difference between
the two groups in receptive spoken
vocabulary scores.
A study by Connor et al. (2000) compared
two groups of children who had cochlear
implants and received different educational
programs. One group had been in
an educational setting using an oral
communication approach while the other
group had been in a different educational
setting using a total communication
approach. In general, the study found no
significant difference between the two
groups when age of cochlear implantation
was taken into account. In total there
were 147 children in the study. The study
looked at the relationships between the
two educational approaches and the
child’s consonant-production accuracy
and vocabulary development over time.
Results showed that children in oral
Another study by Kos et al. (2008) observed
children who had received cochlear
implants later in life and appraised their
language outcomes. This study found that
children who had received cued speech
prior to implantation compared to those
who had received sign language education
were better at vowel and consonant
identification without visual and cognitive
cues. Although, there was no difference
between the two cued speech and signed
groups prior to implantation, therefore the
authors concluded that the impact of cued
speech in relation to vowel and consonant
identification is negligible without cochlear
implantation. In this study, 13 children
were included, with the age of implantation
ranging from 8 to 22 years of age.
Rydberg et al. (2009) considered
educational outcomes resulting from the
bilingual education of deaf children.
The study found limited educational
gain, noting that there was still a gap
between deaf children and their hearing
counterparts in terms of education
outcomes. Whereas a study by Mayer and
Leigh (2010) found there was insufficient
evidence to assess whether children who
undergo bilingual education achieved
similar language and reading outcomes to
children with normal hearing.
4.3.3 Negative findings
Two studies discussed earlier, Tobey et
al. (2004) and Geers and Moog (1992),
compared intervention approaches. Tobey
et al. (2004) found that speech intelligibility
outcomes for children who were in total
communication programs were inferior to
those of children who were in AOT. While
Geers and Moog (1992) also found similar
results as total communication outcomes
were inferior to those from children in AOT.
24
Comparative review of reported outcomes from interventions for children with hearing loss
4.4 Social and wellbeing outcomes
A presentation by Constantinescu et al
(2014) noted that there are no current
studies looking at social inclusion for young
children with hearing loss who are enrolled
in listening and spoken language early
intervention programs. As a result, there
are limited findings reported in this section.
4.4.1 Positive findings
Goldberg and Flexer (2001) considered
the social integration of the individuals
who are deaf or hearing impaired who had
graduated from AVT. In particular, whether
hearing impaired study participants
were married and the rate of divorce.
Overall, 76% of respondents said they
felt like they functioned in the ‘hearing’
world, whereas 21% felt like they were in
both the ‘hearing’ and ‘deaf’ worlds. Of
the 111 respondents, 23 recorded being
married, which the authors used as a
proxy for individuals being in ‘regular’
living environments, however 10 of these
23 also recorded as having their marriage
end in divorce. The study also considered
participation in community activities with
study participants reporting that they
participated in numerous activities.
Duncan (1999) compared conversations of
11 children undergoing AVT to 10 children
with normal hearing. Parameters that
were studied included conversation topic
initiation, maintenance, the shifting of
topics, and conversation termination. The
study found that the results of children
receiving AVT were comparable to those
of the children who had normal hearing
although the results were compromised in
part by the small study sample size.
The wellbeing of families with children
who are deaf was considered by Liliegran
et al. (2012). The authors analysed the
impact AVT had on a caregiver’s level of
empowerment. This study showed that the
duration of AVT and level of empowerment
felt by parents was positively correlated.
The number of hours that parents
25
participate in therapy sessions was also
positively correlated with the level of
empowerment felt by parents.
A study by Greenberg et al. (1984) analysed
a group of children who underwent
simultaneous communication
intervention and the impact this had on
social and communication development.
The study found that children who were
enrolled in the intervention had longer
episodes of social interaction and had on
average a higher number of interactions.
This study compared matched 12 children
who were in the intervention to 12 children
who were not enrolled in the treatment,
but did have hearing loss.
Hyde and Punch (2011) reported on the
use of signed language and its impact on
children’s social circles. It was found that
many children with hearing impairment
who do not have many deaf friends who
sign, or parents who sign, did not feel
connected to a deaf community. This study
also reported that some children in the
study have become more interested with
meeting and mixing with more deaf people.
The Meadow (2005) study also looked into
social functioning, but compared children
who signed and had deaf parents to those
who signed and had hearing parents. In
most cases the children with deaf parents
rated higher than the children with hearing
parents. For example, children with deaf
parents were considered more mature,
responsible, popular and independent
than those with hearing parents. To rate
the social functioning of the children in
the study the author used ratings from
the child’s classroom teacher, dormitory
counsellor and either the vocational arts
teacher or another counsellor. A child with
a hearing parent and a child with a deaf
parent were then matched and results
were compared.
Comparative review of reported outcomes from interventions for children with hearing loss
4.5 Outcomes of multi-disciplinary
interventions and family-based
interventions
There were limited articles that analysed
the impact of multi-disciplinary teams
on outcomes of children with hearing loss.
Of those that did discuss the role of the
multi-disciplinary team, it was mainly to
state that a multi-disciplinary team should
be included in early intervention and in
delivering universal newborn hearing
screening programs. Also of note was the
variability in the composition of multidisciplinary teams.
According to the JCIH (JCIH, 2000), 30-40%
of children with hearing loss demonstrate
additional disabilities. For this reason, JCIH
(2000) state that a multi-disciplinary
approach to assessing children and
developing early interventions should
be utilised. Interestingly, First Voice
(2015) reported that just 11% of program
participants had an additional disability
that impacted on their learning.
Another article by Wiley et al. (2011) re
affirms this finding. Wiley et al. (2011)
performed a chart review of patient’s
charts from a population of 260 children.
Through this analysis they were able to
highlight the importance of involving an
interdisciplinary team when assessing
children with hearing loss. Of the team
involved in this analysis, there were
genetic specialists, ophthalmologists,
developmental paediatrics, speech
pathologists, and aural rehabilitation
specialists. The evaluation provided by
all specialists enabled genetic causes
of hearing loss to be analysed. Of the
group, 27.8% had hearing loss as a result
of genetic causes. From ophthalmologic
assessments, it was found that 57% of
the children had clinically significant
findings. The developmental paediatrics
assessment also found that 69% of the
children who completed an evaluation with
a developmental paediatrician had findings
which could impact their education or
development. Wiley et al. (2011) state that
as a result of these comorbidities, multi-
disciplinary teams should be employed
when assessing children with hearing loss.
Other literature encourages a multidisciplinary approach to managing early
intervention and developing a plan for a
child with hearing loss. Although there
have been limited studies on the outcomes
of multi-disciplinary interventions, a
number of articles discuss the importance
of adopting such an approach for
interventions. As a result of children
with hearing loss being at higher risk of
having additional disabilities, a number of
articles argue that a multi-disciplinary
intervention should be created for the
child so that all conditions of the child are
treated. The JCIH (2000) states that an early
intervention approach should be flexible
and have the ability to be tailored to a
child’s needs, this includes accommodating
their additional disabilities.
An article by Yucel (2008) also provides
an argument for multi-disciplinary
interventions so that the needs of the
parents are addressed. This study surveyed
65 parents of children who were enrolled in
an AVT program which also provided family
counselling services. This study found
that 55.4% of families expressed a need
to talk to someone, indicating that families
needed social support. Of those in the
survey, 78% reported a need in helping to
locate babysitters and 53.4% needed help
in locating day care programs. All these
statistics indicate additional stress for
parents and the need to support families
of children with hearing loss. Yucel (2008)
argues that a multi-disciplinary team
should be employed to ensure that the
needs of the family are met.
A study that looked at the outcomes
of a family-based multi-disciplinary
intervention found an important
relationship between family involvement
and language outcomes. The study by
Moeller (2000) found that children who
had high family involvement in their
intervention had better language outcomes
than those who had lower than average
family involvement. Results also showed
early intervention was more impactful.
Children who had received intervention
services before the age of 11 months had
better outcomes than those that had
received intervention services after 11
months. And although later enrolment
in the therapy was found to negatively
influence language outcomes, this
could be offset by high levels of family
involvement. Together, late uptake and
low levels of family involvement had the
worst rates of language outcomes.
Moeller (2000) also analysed a group of
112 children who were graduates of the
Diagnostic Early Intervention Program.
Following an initial diagnosis and an initial
intervention, program participants are
then referred to an appropriate early
intervention therapy. The children included
in this study either went to an auditoryoral program or a total communication
program. The study found that age of
enrolment and family involvement played
significant roles in language outcomes.
Vocabulary skills of children at five years
of age were assessed through the use
of the Peabody Picture Vocabulary Test
and the Preschool Language Assessment
Instrument. Family involvement was
determined using a rating scale which was
administered to early interventionists who
had contact with the families.
Another study by Nelson et al. (2007)
analysed vowel production in children
with hearing loss who were enrolled
in a family-based multi-disciplinary
intervention. This study found that
children who were enrolled in a familybased multi-disciplinary intervention
had similar vowel acquisitions to those
of hearing children of similar age. Of the
54 children in the study, 52 were enrolled
in the Colorado Home Intervention
Program. The Program is a family-centred
intervention program that provides families
with multi-disciplinary specialists as well
as AVT. The results from this intervention
show the benefits of family-based multidisciplinary approaches.
26
Comparative review of reported outcomes from interventions for children with hearing loss
Conclusion
The foci of this review were primarily
outcomes related to early development
(speech, reading and language) and
learning (schooling and later outcomes)
which arise from different interventions
for hearing impaired children. Social and
wellbeing outcomes were less of a focus
due to limited evidence available on these
outcomes. As noted, the robustness and
transferability of reported outcomes is
compromised to some extent by a lack of
evidence based studies, and absence of
studies which demonstrated sustained
effect at least one year beyond treatment.
Additionally, it is recognised that outcomes
27
are influenced by other independent
factors including the age of onset
of hearing loss and age at aiding
or implantation.
There was negligible literature that
compared the outcomes of multidisciplinary focused interventions with a
sole practitioner approach. Instead the
literature concentrated on the importance
of multi-disciplinary interventions and
screening processes in light of the fact
that some children with hearing loss also
have other disabilities. The small body of
evidence concerning family-based multi-
disciplinary interventions found that family
involvement in any intervention was a key
determinant of successful outcomes.
In summary, the available evidence shows
that the most effective pathway for hearing
impaired children in bringing about early
development, schooling and employment
outcomes is to deliver an intervention with
a multi-disciplinary team and with high
levels of family involvement.
Comparative review of reported outcomes from interventions for children with hearing loss
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Comparative review of reported outcomes from interventions for children with hearing loss
Appendix A: Summary of studies
included in the review
Study
Sample size
Summary of findings
Centre for Allied Health
Evidence (2007)
Literature review
Identified a number of parameters that influence outcomes for children
with hearing impariment.
Kaipa and Danser (2016)
Literature review
AVT has positive speech perception findings and mixed results on rate of
language development.
Sahli and Belgin (2011)
15
AVT resulted in a positive change in the speech perception abilities of
children.
Fairgray et al. (2010)
7
AVT has positive speech perception findings.
Diller et al. (2001)
103
50.5% of children in the sample had hearing level similar to children with
normal hearing and 48.4% had level of speech and language similar to
children with normal hearing.
Eriks-Brophy (2004)
Literature review
Available evidence supports AVT and the potential positive outcomes for
speech, language and reading.
Dornan et al. (2007)
29
AVT results in considerable language growth.
Dornan et al. (2008)
Literature review
Existing literature demonstrated the potential for speech and language
development with AVT.
Dornan et al. (2009)
25
AVT has negligble impact on language growth.
Dornan et al. (2010)
19
Children who underwent AVT did not have statistically significant
different results from hearing children in speech, language and selfesteem.
Econtext (2011)
Literature review and CBA
Positive results for children enrolled in AVT.
Percy-Smith et al. (2010)
155
Found that AVT and AOT were superior to total communication on a
phonological test.
Dettman et al. (2013)
39
Children who used auditory-verbal and auditory-oral communication
had better speech perception and language outcomes than children who
used bilingual-bicultural communication.
Archbold et al. (2000)
46
Children in the oral communication setting outperformed those that
used total communication approaches in terms of speech intelligibility.
Kipila (1985)
1
Deaf children with hearing parents who used cued speech had language
outcomes similar to hearing children.
Metzger (1994)
1
Deaf children with hearing parents who used cued speech had language
outcomes similar to hearing children.
Anthony et al. (1991)
1
Deaf children with hearing parents who used cued speech had language
outcomes similar to hearing children.
Sarant (2016)
Literature review
Children in an oral setting had better speech perception and production
outcomes than children in an oral and sign setting.
Hogan et al. (2008)
37
AVT aids language growth.
Hogan et al. (2010)
49
Children who undertake AVT have considerable growth in language
development.
Rhoades and Chisholm
(2000)
40
AVT aids language growth.
33
Comparative review of reported outcomes from interventions for children with hearing loss
Robertson and Flexer (1993)
37
30 out of the 37 children scored in the 50th percentile or higher on
reading tests when compared to children with normal hearing.
Goldberg and Flexer (1993)
157
Reported positive education, employment and social outcomes for
graduates of AVT.
Tobey et al. (2004)
131
Speech intelligibility within children who had attended AOT programs
was better than children who attended total communication programs.
Goldberg and Flexer (2001)
114
Reported positive education, employment and social outcomes for
graduates of AVT.
Hayes et al. (2009)
65
Mixed findings of AOT. Children with cochlear implants performed below
the average of the hearing group in terms of receptive vocabulary.
Geers and Moog (1992)
227
Children in an auditory-oral program out performed children in
total communication programs in terms of speech perception and
production skills.
Wiefferink et al. (2008)
18
Children who were exposed to simultaneous communication performed
better than children exposed to bilingual communication in terms of
receptive and expressive spoken language development.
Connor et al. (2000)
147
No difference between oral communication and total communication
approaches when age of cochlear implantation was taken into account.
Aparicio et al. (2012)
45
Adults who were exposed to cued speech outperformed those exposed
to auditory-oral settings in reading skills.
Cochard et al. (2003)
53
Cued speech had superior outcomes to sign language and oral setting.
Bouton et al. (2011)
18
Children exposed to cued speech before and after cochlear implantation
had better phonemic awareness and high reading task accuracy
compared to children who had not been exposed to cued speech.
Torres et al. (2008)
4
Children exposed to cued speech were skilled readers compared to
standardised norms for their age groups.
Kos et al. (2008)
13
Children who had received cued speech prior to implantation compared
to those who had received sign language education were better at vowel
and consonant identification without visual and cognitive cues.
Hermans et al. (2008)
87
Positive correlation between vocabulary scores for signing and written
skills was identified for children who used Sign Supported Dutch
and SLN.
Rydberg et al. (2009)
2,144
Analysed educational outcomes of children enrolled in bilingual
education. Found that there was limited educational gain. There was still
a gap between deaf children and their hearing counterparts.
Strong and Prinz (1997)
160
A statistically significant relationship between ASL skill and English
literacy skills was found with English literacy performance increasing with
ASL capability.
Meadow (2005)
59
Children who signed and had deaf parents had higher rates of social
functioning than children who signed and did not have deaf parents.
Hyde and Punch (2011)
409
Many children with hearing impairment who do not have many deaf
friends who sign, or parents who sign, did not feel connected to a deaf
community.
34
Comparative review of reported outcomes from interventions for children with hearing loss
Greenberg et al. (1984)
24
Children enrolled in simultaneous communication intervention had
longer episodes of social interaction and averaged a higher number of
interactions compared to children with hearing loss not enrolled in the
intervention.
Yucel (2008)
65
Conducted a survey of parents of children who were enrolled in an AVT
program. Found that parents needed help with a variety of issues.
Wiley et al. (2011)
260
Analysed patient’s charts of participants to determine whether patients
with hearing loss had other disabilities or medical conditions. Of the
group, 27.8% had hearing loss as a result of genetic causes. From
ophthalmologic assessments, it was found that 57% of the children had
clinically significant findings. The developmental paediatrics assessment
also found that 69% of the children who completed an evaluation with
a developmental paediatrician had findings which could impact their
education or development.
Duncan (1999)
21
The study found that the results of children receiving AVT were
comparable to those of the children who had normal hearing .
Moeller (2000)
112
Positive findings for family based multi-disciplinary interventions.
Nelson et al. (2007)
54
Positive findings for family based multi-disciplinary interventions.
35
Comparative review of reported outcomes from interventions for children with hearing loss
Limitation of our work
General use restriction
This report is prepared solely for the use of First Voice. This
report is not intended to and should not be used or relied
upon by anyone else and we accept no duty of care to any
other person or entity. The report has been prepared for the
purpose of reviewing interventions for children with hearing
impairment. You should not refer to or use our name or the
advice for any other purpose.
36
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