The Volta Review - AG Bell

Volume 113, Number 1 Spring 2013 ISSN 0042-8639

The Volta Review

Alexander Graham Bell Association for the Deaf and Hard of Hearing

The

Volta Narrative Comprehension Abilities of Children with Typical Hearing and Children Using Hearing Aids: A Pilot Study Barbra Zupan, Ph.D., and Lynn Dempsey, Ph.D.

Differences in Spoken Lexical Skills: Preschool Children with Cochlear Implants and Children with Typical Hearing Joan A. Luckhurst, Ph.D., CCC-SLP; Cris W. Lauback, Psy.D.; and Ann P. Unterstein VanSkiver, Psy.D.

A Survey of Assessment Tools Used by LSLS Certified Auditory-Verbal Therapists for Children Ages Birth to 3 Years Old Deirdre Neuss, Ph.D., LSLS Cert. AVT; Elizabeth Fitzpatrick, Ph.D., LSLS Cert. AVT; Andrée Durieux-Smith, Ph.D.; Janet Olds, Ph.D.; Katherine Moreau, M.A., Ph.D.; Lee-Anne Ufholz, MLIS; JoAnne Whittingham, M.Sc.; and David Schramm, M.D. Interactive Silences: Evidence for Strategies to Facilitate Spoken Language in Children with Hearing Loss Ellen A. Rhoades, Ed.S., LSLS Cert. AVT

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The Volta Review

Spring 2013

Volume 113, Number 1

The Volta Review

Volume 113, Number 1 Spring 2013 ISSN 0042-8639

The Alexander Graham Bell Association for the Deaf and Hard of Hearing helps families, health care providers and education professionals understand childhood hearing loss and the importance of early diagnosis and intervention. Through advocacy, education, research and financial aid, AG Bell helps to ensure that every child and adult with hearing loss has the opportunity to listen, talk and thrive in mainstream society. With chapters located in the United States and a network of international affiliates, AG Bell supports its mission: Advocating Independence through Listening and Talking!

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Editors’ Preface

Joseph Smaldino, Ph.D., and Kathryn L. Schmitz, Ph.D.

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Narrative Comprehension Abilities of Children with Typical Hearing and Children Using Hearing Aids: A Pilot Study Barbra Zupan, Ph.D., and Lynn Dempsey, Ph.D. Differences in Spoken Lexical Skills: Preschool Children with Cochlear Implants and Children with Typical Hearing Joan A. Luckhurst, Ph.D., CCC-SLP; Cris W. Lauback, Psy.D.; and Ann P. Unterstein VanSkiver, Psy.D. A Survey of Assessment Tools Used by LSLS Certified Auditory-Verbal Therapists for Children Ages Birth to 3 Years Old Deirdre Neuss, Ph.D., LSLS Cert. AVT; Elizabeth Fitzpatrick, Ph.D., LSLS Cert. AVT; Andrée Durieux-Smith, Ph.D.; Janet Olds, Ph.D.; Katherine Moreau, M.A., Ph.D.; Lee-Anne Ufholz, MLIS; JoAnne Whittingham, M.Sc.; and David Schramm, M.D. Interactive Silences: Evidence for Strategies to Facilitate Spoken Language in Children with Hearing Loss Ellen A. Rhoades, Ed.S., LSLS Cert. AVT

Book Review 75

Building Comprehension in Adolescents Ellen A. Rhoades, Ed.S., LSLS Cert. AVT

Regular Features 77

Information for Contributors to The Volta Review

Permission to Copy: The Alexander Graham Bell Association for the Deaf and Hard of Hearing, as copyright owner of this journal, allows single copies of an article to be made for personal use. This consent does not extend to posting on websites or other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collective works of any type, or for reasale without the express written permission of the publisher. For more information, contact AG Bell at 3417 Volta Place, NW, Washington, DC 20007; email [email protected]; or call (202) 337-5220.

The Alexander Graham Bell Association for the Deaf and Hard of Hearing Officers of the Association: President, Donald M. Goldberg, Ph.D., CCC-SLP/A, FAAA, LSLS Cert. AVT (OH); President-Elect, Meredith K. Knueve, Esq. (OH); Immediate Past President, Kathleen S. Treni (NJ); Secretary-Treasurer, Ted Meyer, M.D., Ph.D. (SC); Executive Director/CEO, Alexander T. Graham (VA) Board of Directors: Joni Y. Alberg, Ph.D. (NC); Corrine Altman (NV); Rachel Arfa, Esq. (IL); Evan Brunell (MA); Wendy Deters, M.S., CCC-SLP, LSLS Cert. AVEd (IL); Kevin Franck, Ph.D., MBA, CCC-A (MA); Catharine McNally (VA); Lyn Robertson, Ph.D. (OH)

The Volta Review Editor: Joseph Smaldino, Ph.D. Senior Associate Editor: Kathryn L. Schmitz, Ph.D. Associate Editors: Tamby Allman, Ed.D.; Jessica Bergeron, M.E.D.; Paula Brown, Ph.D., CCC-SLP; Jill Duncan, Ph.D., LSLS Cert. AVT; Rebecca M. Fischer, Ph.D., CCC-A, LSLS Cert. AVT; Marianne Gustafson, M.S., CCC-SLP; Holly B. Keddington, M.S., M.A., Ph.D.; Jane Madell, Ph.D., CCC-A/SLP, LSLS Cert. AVT; Kevin Miller, Ed.D., CCC-SLP, CED; Jan Allison Moore, Ph.D.; Katherine Pike, Au.D.; Ellen Rhoades, Ed.S., LSLS Cert. AVT; Jane Seaton, M.S., CCC-A/SLP; Barbra Zupan, Ph.D. Review Panelists: Anne Beiter, Sandy Bowen, Janet Brown, Teresa Caraway, Diana Christiana, Terrell Clark, Rick Durity, Jan Gatty, Phoebe Gillespie, Melody Harrison, Susan Lane, Marybeth Lartz, Susan Lenihan, John Luckner, Janie Luter, Jane Madell, Kevin Miller, Teri Ouellette, Anne Oyler, Christina Perigoe, Katherine Pike, Ellen Rhoades, Sharon Ringwalt, Barb Robinson, Jack Roush, Jane Seaton, Donna Sorkin, and Rosalie Yaremko The Volta Review Staff: Managing Editor, Melody Felzien; Director of Communications and Marketing, Susan Boswell General Information: The Volta Review (ISSN 0042–8639) is published three times annually. Periodicals postage is paid at Washington, DC, and other additional offices. Copyright Ó 2013 by Alexander Graham Bell Association for the Deaf and Hard of Hearing, 3417 Volta Pl., NW, Washington, DC 20007. Visit us online at www.listeningandspokenlanguage.org. Postmaster: Send address changes to Alexander Graham Bell Association for the Deaf and Hard of Hearing, Attn: Membership Department, 3417 Volta Pl., NW, Washington, DC 20007-2778. Telephone – (202) 337-5220 (voice)/(202) 337-5221 (TTY). Claims for undelivered journal issues must be made within four months of publication. The Volta Review is sent to all premium, student, senior, household and lifetime members of the association. Yearly individual membership dues are: Premium: $60; Household, $75; Senior, $40; Student $30; Life membership, $1,000. Yearly dues for residents of other countries: add $15 U.S. The Volta Review comprises $18 of membership dues. Subscriptions for schools, libraries, institutions are $115 domestic and $135 international (postage included in both prices). Back issues, when available, are $10 each plus shipping and handling. The Volta Review is abstracted and indexed in Applied Social Science Index and Abstracts, Chicorel Abstracts to Reading and Learning Disabilities, Cumulative Index to Nursing & Health Literature, Current Index to Journals in Education, Educational Resources Information Center (ERIC), Elsevier’s Bibliographic Databases, Exceptional Child Education Resources, Language Behavior Abstracts, Mental Health Abstracts, Psychological Abstracts, and Rehabilitation Literature. It is abstracted in PsychINFO and is indexed in Educational Index. The Volta Review is the peer-reviewed scholarly research journal, published three times per year, of the Alexander Graham Bell Assocation for the Deaf and Hard of Hearing, a not-for-profit organization. Annual membership dues are $60 for individuals and $115 (domestic) for institututional subscriptions. The publishing office of The Volta Review is located at 3417 Volta Place, NW, Washington, DC 200072778.

Editors’ Preface

Joseph Smaldino, Ph.D., Editor

Kathryn L. Schmitz, Ph.D., Senior Associate Editor

The Volta Review continues to expand its services to readers and authors alike. In December 2012, The Volta Review began providing a continuing education opportunity for self-study of the journal. For the first time, readers can earn continuing education units (CEUs) for simply doing what they’ve always done: reading and learning about the latest research supporting listening and spoken language outcomes in children who are deaf or hard of hearing. The primary goal of the CEU program is to provide accessible and cost effective continuing education opportunities for professionals who are certified Listening and Spoken Language Specialists (LSLSe) and for those who are seeking the credential. By offering a CEU opportunity, AG Bell is able to take advantage of its new website by offering The Volta Review CEUs as a feature of the Listening and Spoken Language Knowledge Center. This will mark the first time that AG Bell is able to tie together The Volta Review, professional development, and the website. CEU quizzes are currently available for new editions. To access the CEU opportunity, please visit The Volta Review online at ListeningandSpokenLanguage.org/TheVoltaReview. AG Bell is also committed to incorporating research into best practices. As part of this commitment, AG Bell will once again offer its Listening and Spoken Language Symposium on July 18–20, 2013 in Los Angeles, Calif. This year’s Symposium will focus on ‘‘Delivering Quality Services to Families,’’ a theme that will be supported through presentations that integrate research, technology, and best practices. Much of the research published in The Volta Review is tied to clinical application, and what better place to meld research and application together then at the premier professional development opportunity for professionals who support children with hearing loss. To learn more or register, visit ListeningandSpokenLanguage.org. This issue provides evidence to support many aspects of language development for young children with hearing loss learning to listen and talk. Two studies focus on speech and literacy, adding evidence to a growing body of research that shows children who receive early intervention can and do have

language skills on par with their peers who have typical hearing. Another study focuses on professionals and evaluation, highlighting the types of evaluation tools practitioners use and exposing the need for more universal assessment tools to gauge the language development of young children with hearing loss. Finally, another study highlights how interactive silence can be used to improve literacy and language skills. The Volta Review has strived to be a publisher for new authors and professionals in the field. With tools available at ListeningandSpokenLanguage.org/ The VoltaReview, we hope that you will find the right guidance for creating and submitting a manuscript for peer review. As always, please don’t hesitate to contribute to The Volta Review. Sincerely,

Joseph Smaldino, Ph.D. Professor, Department of Communications Sciences Illinois State University [email protected]

Kathryn L. Schmitz, Ph.D. Associate Professor and Associate Dean for Academic Administration National Technical Institute for the Deaf/Rochester Institute of Technology [email protected]

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The Volta Review, Volume 113(1), Spring 2013, 5–27

Narrative Comprehension Abilities of Children with Typical Hearing and Children Using Hearing Aids: A Pilot Study Barbra Zupan, Ph.D., and Lynn Dempsey, Ph.D. This pilot study explores differences in oral narrative comprehension abilities between children with moderate-to-severe sensorineural hearing loss using hearing aids and their peers with typical hearing matched for age and gender. All children were between 3.5 and 5 years of age. Participants were read a patterned, illustrated storybook. Modified versions of this narrative were then read for a Joint Story Retell task and an Expectancy Violation Detection Task to measure both comprehension of key story elements and comprehension monitoring ability. Speech perception was also assessed. Analyses revealed no statistically significant differences between children with and without hearing loss, but interesting trends emerged. Explanations for the stronger than expected performance of the children with hearing loss on the narrative comprehension measures are discussed. Importantly, this pilot study demonstrates that the joint story retell task and expectancy violation detection task are viable measures of narrative comprehension for children with hearing loss. Narratives are prevalent and developmentally important in the everyday lives of young children (Botting, 2010; Boudreau, 2008; Skarakis-Doyle & Dempsey, 2008a). Typically, children are exposed to narratives early and frequently, through both personal storytelling and storybook reading (Boudreau, 2008; Crosson & Geers, 2001; Justice, Swanson, & Buehler, 2008; Lynch et al., 2008; Skarakis-Doyle & Dempsey, 2008a). Hearing loss reduces a child’s access and exposure to narratives, with potentially detrimental effects on the development of narrative comprehension skills (Crosson & Geers, 2001; Barbra Zupan, Ph.D., is an Associate Professor in the Department of Applied Linguistics at Brock University in Ontario, Canada. Lynn Dempsey, Ph.D., is an Associate Professor in the Department of Applied Linguistics at Brock University in Ontario, Canada. Correspondence concerning this manuscript may be addressed to Dr. Zupan at bzupan@ brocku.ca. Narrative Comprehension in Children Using Hearing Aids

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Massaro & Light, 2004; Pittman, 2008). Deficits in prerequisite linguistic skills, such as phonological coding (Carney & Moeller, 1998; Mayberry, Del Giudice, & Lieberman, 2011; Robertson, Dow, & Hainzinger, 2006; Young et al., 1997), and a reported preference for the visual portion of complex auditory-visual (AV) signals (Schorr, Fox, van Wassenhove, & Knudsen, 2005), may also restrict the development of narrative skills in children with hearing loss. However, because studies examining how children with hearing loss cope with verbal discourse are rare (Ibertsson, Hansson, Maki-Torkko, Willstedt-Svennssson, & Sahlen, 2009), the extent and nature of narrative deficits experienced by this population is not well understood. Given that narrative skills are interconnected with the development of language and literacy, and thereby a crucial medium for academic and social learning (Botting, 2002; Boudreau, 2008; Paris & Paris, 2003; Petersen, Gillam, & Gillam, 2008), investigations into the ability of young children with hearing loss to engage in and learn from narratives are a vital component of an overall analysis of the development and functioning of these children.

The Impact of Hearing Loss on the Comprehension of Oral Narratives Comprehending an oral narrative requires that children create a complete and accurate mental representation of what they hear, and then make any necessary inferences required for accurate interpretation (Kendeou, BohnGettler, White, & van den Broek, 2008; Lynch et al., 2008). The mental representation must contain all key narrative elements (e.g., agents, locations, objects, actions) arranged in the appropriate temporal and causal sequence (Skarakis-Doyle & Dempsey, 2008a; van den Broek et al., 2005). Hence, narrative comprehension depends on the development of a myriad of other knowledge processes, including semantic and syntactic knowledge, as well as knowledge about people’s mental states, behavior, and daily events (Lynch et al., 2008; Nelson, 1996; Skarakis-Doyle, Dempsey, & Lee, 2008; Stein & Albro, 1996). The ability to form narrative representations that contain story-specific information typically develops between the ages of 3 and 5 years old (Dempsey, 2005; Stein & Albro, 1996; Trabasso & Nickels, 1992; van den Broek, Lorch, & Thurlow, 1996). Children who use hearing aids may reach this milestone later than their peers, despite advances in identification, intervention practices, and improvements in hearing technology, all of which have contributed to improved acquisition of speech and language skills (Justice et al., 2008; Worsfold, Mahon, Yuen, & Kennedy, 2010). Deficits in vocabulary and grammatical comprehension (Carney & Moeller, 1998; Fagan & Pisoni, 2010; Robertson et al., 2006; Young et al., 1997) and limitations in world experience (Easterbrooks, Lederberg, & Connor, 2010) persist, potentially impeding narrative language 6

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comprehension. This is because children who use hearing aids continue to receive a distorted auditory signal, complicating the perception and discrimination of verbal messages (Zupan, 2013). This makes the integration of the vocabulary, grammar, and world knowledge contained in oral narrative difficult (Lynch et al., 2008; Skarakis-Doyle & Dempsey, 2008a; van den Broek et al., 2005). Children with hearing loss may also face challenges in oral narrative comprehension because of their reported tendency to prefer visual information when faced with a complex AV signal (Bergeson, Houston, & Miyamoto, 2010; Erber, 1972; Schorr et al., 2005; Seewald, Ross, Giolas, & Yonovitz, 1985), particularly when their access to sound comes later in life or is less than ideal (Bergeson, Pisoni, & Davis, 2005; Rouger, Fraysse, Deguine, & Barone, 2007; Tremblay, Champoux, Lepore, & Theoret, 2010). Napolitano and Sloutsky (2004) suggest that a preference for auditory information is important for language processing because it allows children to focus on the transient and continually changing sounds that comprise words. Thus, inattentiveness to the auditory portion of an AV signal may negatively affect how children with hearing loss process language, including narrative forms. Comprehension monitoring may also be disadvantaged by the use of hearing aids. Comprehension monitoring is an important component of narrative comprehension that requires the ability to detect and correct problems in the narrative representations formed (Skarakis-Doyle & Dempsey, 2008a). Research has shown that typically developing children can detect violations made to familiar script-based story material as early as 30 months of age (SkarakisDoyle, 2002). By 4 years of age, they are able to recognize disruptions to story goals and other story errors (Hudson, 1988; Skarakis-Doyle & Dempsey, 2008b). As is the case with primary narrative comprehension, comprehension monitoring requires a coalition of skills including receptive vocabulary, grammatical knowledge, knowledge of truth conditions, understanding of narrative content (i.e., key elements), and verbal memory span (SkarakisDoyle, Dempsey, Campbell, Lee, & Jaques, 2005). Given that many children with hearing loss have deficits in these component skills, problems with comprehension monitoring might also be expected. In a review of literature, only one study was found to have examined narrative comprehension in children with hearing loss who use hearing aids. In that study, Roberston and colleagues (2006) used a story retell procedure that measured both comprehension and production abilities in a group of 10 children with hearing loss (7 hearing aid users; 3 cochlear implant users) and 11 children with typical hearing. Overall, analyses showed that both groups of children were able to engage in story retell when prompted by their parents, providing a similar number of words and phrases in their narratives. However, the children with hearing loss were found to need more parental facilitation (e.g., leading questions) than their peers with typical hearing. It is unclear whether this is indicative of poorer narrative comprehension skills or whether Narrative Comprehension in Children Using Hearing Aids

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it reflects underlying deficits in other skills required by the task (e.g., verbal working memory and verbal formulation), or both. As Skarakis-Doyle & Dempsey (2008a) have pointed out, because traditional story retell tasks require a complex array of skills, conclusions about narrative comprehension may be confounded, resulting in underestimates of children’s narrative comprehension skills.

The Current Study In this pilot study, narrative comprehension measures that place limited demands on working memory and expressive language relative to traditional story retell tasks were used—one for primary comprehension (Joint Story Retell; JSR) and one for comprehension monitoring (Expectancy Violation Detection Task; EVDT; Skarakis-Doyle & Dempsey, 2008a; Skarakis-Doyle et al., 2008). Both measures have been shown to be reliable and valid measures of oral narrative comprehension for typically developing children and children with language delays, ages 30 months to 5 years (Dempsey & Skarakis-Doyle, 2001; Skarakis-Doyle, 2002; Skarakis-Doyle & Dempsey, 2008b; Skarakis-Doyle et al., 2008), but have never before been used with children with hearing loss. Speech perception was also examined in order to evaluate the influence of processing preferences on narrative comprehension abilities. As discussed previously, children with hearing loss have been shown to rely more on the visual portion of AV speech signals, while children with typical hearing tend to rely on the auditory portion (Schorr et al., 2005). Since storybook comprehension requires the reader to process a verbal message while simultaneously attending to story illustrations, the authors of this study wanted to explore whether AV speech perception was related to the narrative comprehension abilities of children who use hearing aids. Specifically, this pilot study addressed the following research questions: 1. Do young children who use hearing aids differ from typically developing children in their comprehension of an orally presented story, as indicated by the number of key story elements supplied during a JSR? The authors hypothesize that children using hearing aids would identify fewer key semantic elements in the JSR task than children with typical hearing. 2. Do young children who use hearing aids differ from typically developing children in their ability to monitor their comprehension of a story, as indicated by the number of story violations detected during a re-reading of a target story? The authors hypothesize that children using hearing aids would detect fewer violations in the EVDT task than children with typical hearing. 3. Are differences in processing preferences evident in children who use hearing aids and children with typical hearing evident, and do these differences correlate with narrative comprehension skills? The authors 8

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hypothesize that a preference for the visual portion of an AV speech stimulus by children with hearing loss would interfere with their ability to form complete and accurate mental representation of an oral narrative.

Method Participants Five children with hearing loss (2 males; 3 females) and 5 children with typical hearing, matched for gender and age, participated in this pilot study. Children with hearing loss used hearing aids and ranged in age from 41 to 67 months (M¼ 54.20, SD¼11.82). The age range for children with typical hearing was 40 to 65 months (M ¼ 52.20, SD ¼ 11.39). An independent samples t-test confirmed that the two groups of children were successfully age-matched, t(8) ¼2.72, p¼.79. All children with hearing loss had been diagnosed with at least a moderate sensorineural hearing loss in both ears. Table 1 shows the level of hearing loss, age at which hearing aids were received, duration of hearing aid use, and intervention type for each child. All of the children with hearing loss had parents with typical hearing and no identified additional developmental challenges. Participants were recruited through local agencies that offer support and clinical services to children with hearing loss. Children with typical hearing were recruited through local daycare, preschool education, and community facilities. Speech and Language Measures All children completed standardized speech and language testing. Receptive vocabulary was assessed using the Peabody Picture Vocabulary Test–III, Table 1. Descriptive information for children with hearing loss using hearing aids

Participant HL1 HL2 HL3 HL4 HL5 Mean SD

Level of Hearing Loss Bilateral Moderate-Severe Bilateral Moderate-severe Bilateral Moderate-Severe Bilateral Moderate Left Ear-Profound; Right Ear-Moderate-severe

Age Length Age at HAsa of HAsa time of Received Use studya 4 6 4 18 42

50 35 40 47 25

54 41 44 65 67

14.8 16.28

39.4 9.96

54.2 11.82

Type of Intervention Auditory-Verbal Auditory-Verbal Auditory-Oral Auditory-Verbal Auditory-Verbal

Note. HL ¼ hearing loss; HA ¼ hearing aid; SD ¼ standard deviation a recorded in months.

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(PPVT-III; Dunn & Dunn, 1997) and receptive language was assessed using the receptive subtest of the Test of Early Language Development–3 (TELD-3; Hresko, Reid, & Hammill, 1999). Researchers also administered the Macarthur Communicative Development Inventory–III (MCDI-III; Fenson et al., 2007), a parental report tool that measures global language ability. The MCDI-III consists of a 100-item expressive vocabulary checklist, a 12-item grammatical structures checklist, and 12 general questions regarding children’s use of language. Speech sound production skills were assessed with the GoldmanFristoe Test of Articulation–2 (GFTA-2; Goldman & Fristoe, 2000). Speech sound production errors involving sounds differing by one phonetic feature (e.g., /d/ vs. /g/) are common in children with hearing loss and could potentially lead researchers to incorrectly interpret verbal responses (Mildner, Sindija, & Zrinski, 2006). Therefore, this testing was completed so researchers could be confident that the verbal responses provided by both groups of children were being accurately decoded by examiners. Parents of children with hearing loss were also asked to complete the Meaningful Auditory Integration Scale (MAIS; Robbins, Renshaw, & Berry, 1991). The MAIS consists of 11 questions about the consistency with which the hearing device is used and how children respond to sound in everyday environments while using the hearing device. Stimuli Narrative Comprehension Researchers employed Splish Splash (Skarakis-Doyle & Wootton, 1995), a patterned story (i.e., repeated syntactic frames, vocabulary, and episodes) revolving around bath time. This story was specifically written for use with the JSR and EVDT tasks and is told in five episodes organized around a muddy girl’s repeated attempts to evade a bath. Because the story event is familiar, children can utilize their bath time scripts to build narrative representations; this provides an important memory scaffold for young participants (SkarakisDoyle et al., 2008). The book contains color illustrations and eight pages of text (see Skarakis-Doyle et al., 2008, for detailed structural information and a sample of the story). Primary story comprehension was measured with the JSR using a modified version of the Splish Splash story in which 10 of the original story elements were omitted from the story to create a cloze task [e.g., So she___(put) her big toe into the bathtub. . .]. Children who have constructed an accurate representation of the narrative should be able to use their understanding of the context to provide the appropriate story elements (Skarakis-Doyle & Dempsey, 2008a). Comprehension monitoring was assessed with the EVDT using a violation version of the story (Skarakis-Doyle, 2002; Skarakis-Doyle & Milosky, 1999) in which eight of the original story elements were altered or violated (e.g., One day a little frog 10

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named Sarah...). The ability to detect narrative violations indicates that a child is making accurate judgments about the success of his/her comprehension (Skarakis-Doyle, 2002; Skarakis-Doyle & Dempsey 2008b). The cloze and violation versions of the story are slightly shorter than the original story but resemble the original in all other respects (see Skarakis-Doyle et al., 2008, for more detailed information on and further samples of the close and violation versions of Splish Splash). Speech Perception The stimuli created for the speech perception task were designed for use within a McGurk paradigm (McGurk & MacDonald, 1976), in which a visual phonemic segment (e.g., /ga/) is combined with an incongruent auditory segment (e.g., /ba/), resulting in an altered, integrated percept (e.g., /da/). A single female speaker was recorded producing the phonemic segments /aga/ and /aba/. Visual recording was completed using a SONY DCR-DVD 108 Handycam digital video camera at a distance of 1.5 meters so only the speaker’s head and shoulders were included in the visual frame. The speaker’s voice was recorded using an Olympus DS-30 Digital Voice Recorder. The visual and auditory segments were then edited and combined as either congruent phonemic segments (e.g., auditory /aba/ paired with visual /aba/) or incongruent phonemic segments (e.g., auditory /aba/ paired with visual / aga/) using Magix Movie Edit Pro 12 software.

Procedure Testing took place in participant homes, a university lab, and at participant schools, depending on parental preference. All testing was conducted in a quiet, well-lit, and distraction-free room, and lasted between 1.0 to 2.5 hours. Portions of the testing were videotaped for later clarification and analysis. To maintain attention and engagement throughout the session, standardized language measures were interspersed with study tasks in a standard pattern across participants (see Figure 1). While children completed the study protocol, parents and caregivers completed a series of questionnaires. The literacy questionnaire, developed by Dempsey and Skarakis-Doyle (2001) for other studies of oral narrative comprehension, contains questions about the frequency of storybook reading both within and outside the home and parental book reading style. Since children’s experience with narratives could potentially impact their performance on oral narrative measures, collecting information about the frequency and/or nature of their narrative exposure was important. All parents and caregivers also completed the MCDI-III, providing important global language information. Parents and caregivers of children with hearing loss additionally completed the MAIS. Narrative Comprehension in Children Using Hearing Aids

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Figure 1. Sequence of standard language measures administered and study tasks.

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Joint Story Retell Task Prior to reading the story, children completed a 19-item picture-point vocabulary comprehension test composed of words extracted from the test story (8 verbs, 8 nouns, 2 locative adverbs, and 1 adjective). This test was administered as an indicator of the participants’ familiarity with the story vocabulary outside of the narrative context. Then, children were read Splish Splash while seated next to the examiner. Following the story, children completed four practice cloze sentences to ensure they understood the demands of the cloze task. All participants successfully completed at least one practice item and, thus, were permitted to continue with the experimental task. After completing the practice items, children were told that the examiner would read Splish Splash again, but that this time they could ‘help’. The examiner then began the JSR task, reading the cloze version of the story and pausing at the 10 predetermined points to allow children to supply the next word(s) (e.g., I need my ____ ). At each ‘blank’ in the story, the examiner paused for 5 seconds and allowed the child an opportunity to supply the missing content. If the child did not respond, the examiner repeated a short section of the text preceding the blank and paused again. If after two attempts no response was elicited from a child, the examiner completed the blank herself and continued with the story. No explicit feedback was provided to children on their performance during the task. The maximum raw score for the JSR task is 10, one point for each correct item. Responses that conveyed the same meaning as the words in the original story were scored correct. Raw scores were converted to a percentage scores for data analysis. Expectancy Violation Detection Task Comprehension monitoring was tested using the EVDT. Participants first completed a practice period during which they were read a short story containing the names of several common animals. As the examiner read the story, she deliberately misnamed the animals and prompted the children to catch her mistakes. Verbal reinforcement was provided for successful catches. All children demonstrated understanding of the EVDT by protesting at least one violation during the practice period, and thus were eligible to continue to the test phase. In this phase the examiner told children that she would read the Splish Splash story again, but this time she ‘‘might be silly or make some mistakes.’’ Children were instructed to try to catch these mistakes. The examiner then read the violation version of the story. No feedback on performance was provided during the task. The EVDT contains a total of eight violations and thus has a maximum score of 8. Responses to the EVDT were scored from videotape using procedures developed by Skarakis-Doyle (2002). To merit a point, responses to violations Narrative Comprehension in Children Using Hearing Aids

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had to occur within 5 seconds of the violation and no later than the end of the phrase immediately following the violation. Both verbal and nonverbal responses were accepted. Verbal responses included single-word protests (e.g., ‘‘No!’’), repetitions of the violation (e.g., ‘‘Mom!’’), and corrections (e.g., ‘‘Not Mom. Sarah!’’). Acceptable nonverbal responses included changes in eye gaze, facial expression, and body position. Skarakis-Doyle (2002) previously demonstrated that these nonverbal behaviors are reliable indicators of detection. Total score out of 8 on the task was obtained by determining the number of violations responded to by each child. This raw score was then converted to a percentage score for data analysis. Speech Perception Task Immediately prior to beginning the speech perception task, children participated in a training task that taught them to associate the segments /aba/, /ada/, and /aga/ with three different toys, and then with pictures of those toys. Avariety of strategies were used to help promote association of each sound with its corresponding toy and then with its picture. These included asking the children to repeat the name of the toy following a model and having them point to the corresponding toy and/or picture on request. The average length for the training period was approximately 1 minute. Once a child had accurately pointed to the picture associated with each of the three sound segments five times, the test phase began. To complete the speech perception task, children were seated comfortably in front of a computer with a 14.5 inch monitor placed approximately 50 centimeters from them on the table. External speakers were placed on either side of the screen and set to play auditory stimuli at 70 dB SPL. A key-pad with three buttons was placed on the table in front of the child. Above each response option (i.e., /aba/, /ada/, and /aga/) was a picture of the corresponding toy from training. To ensure that children were comfortable with the computer task used in the test phase and reliably associating each sound segment with the corresponding picture on the key-pad, practice items were administered. In the practice block, children were asked to confirm their selections before the examiner entered their responses on the key-pad. The practice block included a total of 10 randomized stimuli comprised of four congruent and six incongruent phonemic segments. Stimuli used in the practice block were not used in the test blocks. For both the practice and test blocks, children were instructed to watch and listen to the video of a lady who was going to appear on the screen and ask for a toy. They were instructed to point to the picture of the toy corresponding to the lady’s request. The examiner then pressed the button on the key-pad underneath that picture. This two-step response procedure was implemented to reduce impulsivity and the potential of unintended responses. All children correctly identified at least three of the four congruent stimuli in the practice block, indicating task comprehension. 14

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The speech perception task consisted of two blocks of stimuli, each consisting of 10 congruent trials and 25 incongruent trials, for a total of 20 congruent and 50 incongruent stimuli. The blocks were administered in a counter-balanced order across participants and stimuli within each block were randomized using Superlab 4.5 software (Cedrus Corporation, 2011). Each block took approximately 5 minutes to complete. Responses were recorded both manually and on videotape to ensure accuracy in scoring and prevent data loss associated with equipment error. Responses to congruent stimuli in the speech perception task were scored as correct and assigned 1 point if children correctly matched the corresponding toy to the AV stimulus presented. Maximum score for these stimuli was 20. The raw score out of 20 was then converted to a percentage score for data analysis. Incongruent stimuli had no correct responses. Instead, responses were coded into one of three categories: (1) a response consistent with the visual portion of the stimulus (/aga/); (2) a response consistent with the auditory portion of the stimulus (/aba/); or (3) a response indicating integration of the two sources of information (/ada/). Scoring was completed by calculating the total number of auditory based responses, number of visually based responses, and number of integrated responses provided by each participant. Each of these scores was then converted to a percentage score that represented the proportion of total responses that fell into each response category.

Results Language, Literacy, and Speech Sound Production Skills Given the potential contribution of receptive vocabulary and grammatical skills to the successful construction of narrative representations (SkarakisDoyle & Dempsey, 2008a; Stein & Albro, 1996), scores on the PPVT-III, the receptive subtest of the TELD-3, and the MCDI-III were compared between groups. Children in both groups scored within normal limits for their age on both the PPVT-III and TELD-3. No statistically significant differences were found between groups when independent samples t-tests were conducted for each measure. Mean standard scores, standard deviations, and results of the ttests are presented in Table 2. A review of parents’ responses to the literacy questionnaire indicated high levels of narrative exposure in both groups. Parents reported that children in both groups enjoyed reading books and were read to at least once daily. In addition, over half of the parents across both groups reported engaging their children in the stories using various literacy strategies, such as question-asking and intentional plot violations. Overall, there were striking similarities between the two groups in terms of their literacy exposure. Speech sound production skills were assessed using the GFTA-2. A variety of articulation errors were noted, many of which were age appropriate. Narrative Comprehension in Children Using Hearing Aids

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Table 2. Means, standard deviations of standard scores, and results of independent samples t-tests for language tests by group

PPVT-III TELD-3 MCDI-III

Hearing Loss

Typical Hearing

M

SD

M

SD

Group comparison

100.20 119.20 76.78

7.50 14.32 12.91

107.60 113.20 73.0

17.63 16.33 28.21

t(8) ¼ .86, p ¼ .41 t(8) ¼ .62, p ¼ .55 t(8) ¼ .38, p ¼ .74

Researchers were most interested in the children’s ability to produce /b/, /d/, and /g/ since the speech perception task was based on these sounds. All of the children with typical hearing clearly produced these three target phonemes at the beginning, middle, and end of words on the GFTA-2. This was also true of all but 1 of the children with hearing loss. That child was only able to produce /g/ correctly in the initial position of words; errors were observed in medial and final position. As this child consistently pointed to the toys associated with the target sounds in the speech perception task (/aba/, /ada/, /aga/), researchers were confident that he perceived the differences among these three phonemes. Oral Narrative Comprehension and Monitoring On average, children with hearing loss correctly pointed to the target vocabulary item in the 19-item prevocabulary test 83% of the time, while children with typical hearing were correct 74% of the time. These results suggested adequate familiarity with the vocabulary contained in the story. Despite their weaker vocabulary results, children with typical hearing obtained slightly higher scores on the JSR than children with hearing loss (Table 3). However, a one-way of analysis of variance (ANOVA), conducted to compare task performance, revealed that the difference between groups was not statistically significant [F(1,9) ¼ .05, p ¼ .83], suggesting that, on average, children in the two groups had similar overall comprehension of the story. A reverse pattern from performance on the JSR was found with the EVDT. For the EVDT, children with hearing loss showed slightly better performance, recognizing violations 47% of the time, compared to children with typical hearing, who recognized violations only 32% of the time. However, again, the difference in mean test scores was not statistically significant, F(1,9) ¼ .39, p¼.55. Mean overall responses and standard deviations for performance on the EVDT are shown in Table 3. Speech Perception To ensure that children were attending throughout the speech perception task and not just randomly pointing to pictures of the toys, researchers 16

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Table 3. Responses to narrative comprehension measures by children with hearing loss and children with typical hearing Hearing Loss

JSR EVDT

Typical Hearing

M (%)

SD

M (%)

SD

36.0 47.5

20.74 32.36

42.0 32.5

30.33 42.94

analyzed responses to the congruent AV stimuli. Interestingly, children with hearing loss showed more accurate identification of these segments, correctly identifying them 81% of the time (SD ¼15.57) compared to 77% (SD ¼ 29.07) by children with typical hearing. A one-way ANOVA indicated that this difference was not statistically significant, F(1, 9) ¼ .074, p ¼ .79. These accuracy levels are well above those expected for chance responding (i.e., 33%), verifying the credibility of participant responses. In addition, these results indicate that participants in both groups were able to perceive and identify each of the phoneme segments included in the speech perception task. Figure 2 shows the proportions of auditory, visual, and integrated response types to the incongruent speech segments for each group. To explore perceptual modality preferences within each group of children, paired sample t-tests were conducted to compare the mean proportion of each response type provided. Family wise error rate was controlled across these tests using Bonferroni’s approach (a ¼ .02). As seen in Figure 2, children with hearing loss provided a similar proportion of auditory-based (37%), visually-based (24%), and integrated responses (40%). This observation was confirmed by a lack of any significant differences on paired-sample t-tests comparing response types for this group. Children with typical hearing showed the greatest difference in response types, providing many more auditory-based responses (72%) than visually-based ones (11%). However, this difference only approached significance, t(4) ¼ 3.06, p ¼ .04. To compare response types provided across the two groups, a 3 3 2 ANOVA was conducted with response type (auditory-based, visually-based, integrated) as the within-subjects factor and hearing status as the between-subjects factor. Hearing status did not significantly impact response type, F(2, 16)¼1.65, p ¼ .22, gp2 ¼ .17, and no main effect of response type was indicated, F(2, 16) ¼ 2.54, p ¼ .11, gp2 ¼ .24. These results were somewhat surprising given the within-group differences reported above, but may simply be a reflection of small sample size.

Discussion The primary aim of this pilot study was to compare the oral narrative comprehension abilities of children who use hearing aids and rely on spoken Narrative Comprehension in Children Using Hearing Aids

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Figure 2. Proportion of auditory-based, visually-based, and integrated responses selected by children with hearing loss and children with typical hearing.

communication to those of children with typical hearing. This study was novel in its use of nontraditional narrative comprehension measures that place few demands on working memory and require limited expressive language. Adding further to the novelty of this study was the use of a tool that specifically measures comprehension monitoring ability. Due to the small number of participants in this pilot, the data cannot be generalized and should be interpreted carefully. Nevertheless, the overall picture that emerged suggests that some children with moderate-severe hearing loss who rely on hearing aids to access sound can understand oral narratives at a level on par with their peers who have typical hearing. In addition, these children may differ very little from their peers in domains known to contribute to oral narrative comprehension (e.g., vocabulary comprehension, literacy experience). The first aim of this pilot study was to investigate whether young children who use hearing aids differ from children with typical hearing in their ability to supply key story elements in a joint retelling task (i.e., JSR), an indication that a child has grasped vital agents, locations, actions, and objects in the narrative (Dempsey & Skarakis-Doyle, 2001; Skarakis-Doyle & Dempsey, 2008a). Researchers expected that the distortion existing in the hearing aid signal (Friesen, Shannon, Baskent, & Wang, 2001; Turner et al., 1999; Zupan, 2013) would limit the ability of the children with hearing loss to attend to, process, and integrate key linguistic elements during an ongoing oral narrative. Thus, researchers anticipated that these children would identify fewer key story elements than their peers with typical hearing. Prior research has, in fact, reported deficits in the narrative abilities of children with hearing loss, specifically noting that their story retells lacked important key elements 18

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(Luetke-Stahlman, Griffiths, & Montgomery, 1998). Although in the present study the performance of children with hearing loss was slightly poorer than that of the matched group, the difference was not significant, suggesting that children with and without hearing loss are similarly able to supply target word(s) within a cloze test structure. In addition to comparing oral narrative comprehension abilities, this pilot study also aimed to compare comprehension monitoring abilities of these two groups. Since the EVDT requires more sophisticated skills than the JSR, researchers again hypothesized that children with hearing loss would find this task more difficult than children with typical hearing. This hypothesis was not supported. In fact, though the difference was not significant, the children with hearing loss actually detected more violations than the children with typical hearing. Although the results of the oral narrative comprehension group comparisons were at first surprising, there are several potential explanations. First, the children with hearing loss who participated in this investigation were all found to have receptive vocabulary and grammatical abilities within age-expectations. In fact, there were no statistically significant differences between the groups on the PPVT-III, TELD-3, and MCDI-III. Since the linguistic skills measured by these tests contribute to narrative comprehension (Nelson, 1996; Stein & Albro, 1996), the stronger than expected performance by the children with hearing loss on the oral narrative comprehension measures may, in part, be attributable to the strength of their linguistic skills. The reverse pattern has been reported in children known to have language delays. Skarakis-Doyle and colleagues (2008) reported that children with language delays, who had impaired receptive vocabulary and grammatical skills, also performed poorly relative to typically developing children on the JSR and EVDT. This finding is consistent with the suggestion that receptive vocabulary and grammatical skills are key components of oral narrative comprehension. The fact that the children with hearing loss in this investigation had age-appropriate abilities in these domains may then help account for their stronger than expected performance on the JSR and EVDT. Intervention-type may also help account for the stronger than expected performance of children with hearing loss on the oral narrative comprehension measures. All children with hearing loss who participated in the current study were receiving intervention focused on the spoken communication modality: 4 were receiving auditory-verbal therapy and 1 was receiving auditory-oral therapy. Both types of intervention place considerable emphasis on attending to the auditory signal, which encourages active listening through a variety of strategies like acoustic highlighting and the use of parentese (Geers, Nicholas, & Sedey, 2003; Hogan, Stokes, White, Tyszkiewicz, & Woolgar, 2008; Musselman & Kirkcaali-Iftar, 1996). As success on the JSR and EVDT requires that listeners pay close attention to specific aspects of the auditory signal, an intervention focused on audition may benefit children with hearing aids faced Narrative Comprehension in Children Using Hearing Aids

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with these tasks. Children with hearing loss receiving interventions focused on audition are initially bombarded with enhanced suprasegmentals through songs and other activities that focus on recognizing auditory patterns in words, phrases, and sentences (Estabrooks, 2006). Perhaps, then, the children with hearing loss were better able to detect violations in the EVDT-modified story because those violations disrupted the suprasegmental pattern they had associated with the patterned story. Responses to the speech perception task need also be considered as a factor in oral narrative comprehension performance. Although significant differences between response types did not emerge within or between groups, the pattern of performance warrants discussion. Given the results of a previous investigation that reported a preference for visual information in children with cochlear implants (Schorr et al., 2005), researchers hypothesized that the children with hearing loss in the current study would provide significantly more visually-based responses than any other response type. This hypothesis was not supported. Surprisingly, the children with hearing loss provided a similar number of each type of response, with visually-based responses provided least often and integrated responses most (see Figure 2). In contrast, children with typical hearing provided primarily auditory-based responses, a finding that is consistent with previous investigations of modality preferences in typically developing young children (Sloutsky & Napolitano, 2003). The fact that the children with hearing loss provided a relatively high number of integrated responses on the speech perception task helps explain the relative strength of their EVDT performance. Integration of auditory and visual cues is critical for comprehension during a storybook interaction. Because children with hearing loss have a tendency to integrate aspects of the auditory and visual signals, they may have been more adept at combining the auditory and visual cues provided during the storybook readings of Splish Splash. The ability to tune into the visual illustrations while simultaneously processing the oral narratives may have made the material more tangible, allowing the children with hearing loss to create a better framework in which to organize the verbal content (Levin & Mayer, 1993). Similar facilitation effects of illustrations have previously been reported for children without hearing loss (Greenhoot & Semb, 2008). Illustrations are typically representative of the story content, as they were in the case of the test story used in this investigation. So even if the children with hearing loss were not wholly processing the auditory information as the story was read aloud, they may have still been able to sufficiently combine the two sources of information to create a complete schema. This is consistent with research that reports improved perception when visual and auditory sources of information are integrated versus the reliance on information from only one of these modalities (Bergeson, Pisoni, & Davis, 2003; Lachs, Pisoni, & Kirk, 2001; Massaro & Light, 2004). Thus, although a preference for auditory information has been proposed as an important factor in language development in young children (Napolitano & Sloutsky, 2004), the 20

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ability to also draw on visual cues may aid oral narrative comprehension in some populations. In the case of hearing aid users, who receive a distorted auditory signal, such ability may enhance understanding of the narrative, enabling them to form representations and monitor comprehension on par with their peers who have typical hearing. However, it is also important to consider that performance on the speech perception task may instead indicate that modality preferences in processing are flexible in children with hearing loss, with focus given to the modality that contains the most salient cue at the time. Future research on literacy development in children with hearing loss should include auditory-only and/or visual-only versions of the story to allow for more direct observation of the modality relied upon for narrative comprehension. Two important clinical implications arise if children with hearing loss do in fact create more complete narrative schemas when provided with both auditory and pictorial cues. The first concerns book choices. Professionals working with young children with hearing loss (e.g., speech-language pathologists, listening and spoken language practitioners) should instruct parents and teachers in how to evaluate the fit between text and illustration when making selections for joint book reading activities. Parents and teachers should be encouraged to choose books with illustrations that are highly representative of story content. The presence of compatible visual and auditory information may strengthen the representations the children form and optimize their narrative comprehension. The second implication concerns classroom settings. Findings of this study suggest that children using an FM system may still benefit from preferential seating in the early grades where visual supports are often used to enhance lessons. Having a clear view of the visual supports may allow young children with hearing loss to better integrate the information presented to these two modalities, essentially compensating for any degradation in the auditory signal. To summarize, children with hearing loss who participated in the present investigation performed similarly to a group of age-matched children with typical hearing on two measures of oral narrative comprehension. The authors speculated about possible reasons for the relatively strong performance of children using hearing aids on these measures, positing that strong underlying linguistic skills, intensive intervention focused on attending to and processing the auditory signal, and an ability to make use of both auditory and visual information may have been factors. Moreover, the similar amount and type of narrative experience reported for children in both groups may also have contributed to the similarity observed in JSR and EVDT scores. Limitations When interpreting the results of this pilot study, it is important to note the limitations imposed by the relatively small sample size. As a result of the Narrative Comprehension in Children Using Hearing Aids

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sample size, it is not possible to draw conclusions about the interplay among such potentially relevant factors as age of identification or amplification and narrative comprehension ability. As Botting (2010) points out, unravelling the intricate relationships among such factors is a key to understanding the strengths and weakness of children with hearing loss and to developing appropriate supports for them. The small sample size also limits the ability to make generalizations to other hearing aid users engaged in spoken communication as it is unclear whether the full range of narrative ability is represented in the participating sample. Finally, the small sample size means that it is possible there was insufficient power to detect between group differences, which may have been evident with a larger sample. For this reason, the researchers have chosen not to limit discussion solely to statistically significant outcomes, but to examine trends in scores. Importantly, these trends suggest that the nontraditional comprehension measures used in this pilot study can be successfully administered to children who use hearing aids. Further, these measures may more accurately represent the narrative comprehension abilities of children with hearing loss since verbal working memory and expressive language demands are reduced relative to the traditional retell task. However, it is not possible to demonstrate the sensitivity and specificity of the JSR and EVDT in this population without undertaking a larger, more comprehensive study. As discussed by Eriks-Brophy (2004), there is a great need to establish collaborative, multi-center research projects in this field so that more rigorous studies can be conducted. Future studies investigating oral narrative comprehension and potential contributing factors (e.g., language development, speech perception, verbal working memory, and communication mode) would most certainly benefit from such an approach.

Conclusion The outcomes of the current study are encouraging. They suggest that children who use hearing aids and participate in spoken language intervention are able to form story representations that are as detailed and accurate as their peers with typical hearing. As a result, these children appear to understand oral narratives and engage in comprehension monitoring with similar success. For children with hearing loss, as with children who have typical hearing, aptitude in oral story comprehension may hinge on the strength of other related skills (e.g., receptive vocabulary, grammatical ability, and global language ability). The extent to which auditory training is a focus of intervention may also be a contributing factor in the narrative comprehension performance of children with hearing loss. Finally, attention to visual cues and an ability to integrate them with auditory information may facilitate storybook comprehension in children with hearing loss. Tests of these proposals in large-scale, rigorous studies would greatly enhance understanding of narrative comprehension skills in children with hearing loss. 22

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Acknowledgements This work was funded in part through the Humanities Research Institute at Brock University.

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Rouger, J., Fraysse, B., Deguine, O., & Barone, P. (2007). McGurk effects in cochlear-implanted deaf subjects. Brain Research, 1188, 87–99. Schorr, E. A., Fox, N. A., van Wassenhove, V., & Knudsen, E. I. (2005). Auditory– visual fusion in speech perception in children with cochlear implants. Proceedings of the National Academy of Sciences, 102(51), 18748–18750. Seewald, R. C., Ross, M., Giolas, T. G., & Yonovitz, A. (1985). Primary modality for speech perception in children with normal and impaired hearing. Journal of Speech and Hearing Research, 28, 36–46. Skarakis-Doyle, E. (2002). Young children’s detection of violations in familiar stories and emerging comprehension monitoring. Discourse Processes, 33, 175–197. Skarakis-Doyle, E., & Dempsey, L. (2008a). Assessing story comprehension in preschool children. Topics in Language Disorders, 28(2), 131–148. Skarakis-Doyle, E., & Dempsey, L. (2008b). The detection and monitoring of comprehension errors by preschool children with and without language impairment. Journal of Speech, Language and Hearing Research, 51, 1227–1243. Skarakis-Doyle, E., Dempsey, L., & Lee, C. (2008). Identifying language comprehension impairment in preschool children. Language, Speech & Hearing Services in Schools, 39, 54–65. Skarakis-Doyle, E., Dempsey, L., Campbell, W., Lee, C., & Jaques, J. (2005, June). Constructs underlying emerging comprehension monitoring: A preliminary study. Poster session presented at the 26th Annual Symposium on Research in Child Language Disorders, Madison, WI. Skarakis-Doyle, E. & Milosky, L. (1999). Assessing discourse representation in preschool children: Elements of global fast map. Poster session presented at the 20th Annual Symposium for Research in Child Language Disorders, Madison, WI. Skarakis-Doyle, E. & Wootton, S. (1995). An investigation of children with developmental language impairment’s ability to use everyday knowledge in comprehension. In D. MacLaughlin & S. McEwen (Eds.). Proceedings of the 19th Annual Boston University Conference on Language Development, pp. 599– 610. Sommerville, MA: Cascadilla Press. Sloutsky, V. M., & Napolitano, A. C. (2003). Is a picture worth a thousand words? Preference for auditory modality in young children. Child Development, 74(3), 822–833. Stein, N. & Albro, E. (1996). The emergence of narrative understanding: Evidence for rapid learning in personally relevant contexts. Issues in Education 2, 83–98. Trabasso, T., & Nickels, M. (1992). The development of goal plans of action in the narration of a picture story. Discourse Processes, 15, 249–275. Tremblay, C., Champoux, F., Lepore, F., & Theoret, H. (2010). Audiovisual fusion and cochlear implant proficiency. Restorative Neurology and Neuroscience, 28, 283–291. 26

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Turner, C. W., Chi, S., & Flock, S. (1999). Limiting spectral resolution in speech for listeners with sensorineural hearing loss. Journal of Speech, Language, and Hearing Research, 42, 773–784. van den Broek, P., Kendeou, P., Kremer, K., Lynch, J., Butler, J., White, M. J., & Lorch, E. P. (2005). Assessment of comprehension abilities in children. In S. G. Paris & S. A. Stahl (Eds.), Children’s Reading Comprehension and Assessment (pp. 107–130). Mahwah, NJ: Erlbaum. van den Broek, P., Lorch, E. P., & Thurlow, R. (1996). Children’s and adult’s memory for television stories: The role of causal factors, story-grammar categories, and hierarchical level. Child Development, 67, 3010–3028. Worsfold, S., Mahon, M., Yuen, H., & Kennedy, C. (2010). Narrative skills following early confirmation of permanent childhood hearing impairment. Developmental Medicine & Child Neurology, 52, 922–928. Young, G. A., James, D. G. H., Brown, K., Giles, F., Hemmings, L., Hollis, J.,. . .Newton, M. (1997). The narrative skills of primary children with a unilateral hearing impairment. Clinical Linguistics and Phonetics, 11(2), 115– 138. Zupan, B. (2013). The role of audition in audiovisual perception of speech and emotion in children with hearing loss. In P. Belin, S. Campanella, & T. Ethofer (Eds.), Integrating the Face and Voice in Person Perception (pp. 299–323). New York: Springer.

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The Volta Review, Volume 113(1), Spring 2013, 29–42

Differences in Spoken Lexical Skills: Preschool Children with Cochlear Implants and Children with Typical Hearing Joan A. Luckhurst, Ph.D., CCC-SLP; Cris W. Lauback, Psy.D.; and Ann P. Unterstein VanSkiver, Psy.D. Children with significant hearing loss may experience great difficulty developing spoken language and literacy skills to a level commensurate with children of the same age with typical hearing. While studies of children who use cochlear implants show improved spoken language outcomes in some cases, when compared to the same children’s earlier use of hearing aids only, many still lag behind children with typical hearing. The current study examines levels of spoken lexical language in preschool children with cochlear implants compared to children with typical hearing, matched for age and gender and with control for nonverbal IQ. Outcomes indicate that preschool children with cochlear implants achieve spoken lexical skills within the average range when compared to children of the same age with typical hearing. Results support the evidence that early cochlear implantation provides good benefit for spoken language outcomes.

Lexical Development Early lexical development plays an important role in children’s language skills and literacy development. Though the rate of lexical development can vary widely among children, research has shown early lexical development to be a strong predictor of later success in literacy (Bowyer-Crane et al., 2008; Harlaar, Hayiou-Thomas, Dale, & Plomin, 2008; Muter, Hulme, Snowling, & Joan A. Luckhurst, Ph.D., CCC-SLP, is an Assistant Professor in the Speech-LanguageHearing Science Program at La Salle University. Cris W. Lauback, Psy.D., is an Associate Professor of School Psychology in the Division of Counseling and School Psychology at Alfred University. Ann P. Unterstein VanSkiver, Psy.D., currently works at Eastern State Hospital in Virginia. Correspondence concerning this manuscript may be addressed to Dr. Luckhurst at [email protected]. Effect of Cochlear Implants on Lexical Language

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Stevenson, 2004; Rescorla, 2005; Shanahan, 2006). Evidence also suggests that many factors impact lexical development, including child factors (i.e., phonological memory skills, ongoing cognitive development, and hearing sensitivity) and environmental factors (i.e., the amount of time a child is spoken to, the amount of speech a child hears, the nature of the speech a child hears, the timing of the speech directed toward a child in response to focus of attention, and socio-economic status [SES]) (Hoff, 2009; Owens, 2008). Children who are developing typically begin recognizing words as early as 5 months of age, demonstrate understanding of word meaning by 10 months of age, produce true words between 10 and 15 months of age, and have a spoken vocabulary of 50 words by the time they reach their second birthday (Hoff, 2009; Owens, 2008). Hearing loss, however, has a dramatic impact on this development (Hoff, 2009). Impact of Severe to Profound Hearing Loss While early development of joint attention and gestural communication is similar for both groups, children with hearing loss need significant educational and audiological intervention to prevent delays in all areas of spoken language—the greater the hearing loss, the more profound the impact (Hoff, 2009). Delays in lexical development of children with hearing loss are characterized by word knowledge that is incomplete and limited to concrete words, with subsequent inflexible use and understanding of vocabulary (Hoff, 2009). In recent years, advances in technology have provided greater access to spoken language for children with severe to profound hearing loss. In 1990, the U.S. Federal Drug Administration (FDA) approved use of cochlear implants (CI) with children (Tye-Murray, 2009). Prior to this time, children with hearing loss had to rely on hearing aids to gain access to sound. While hearing aids benefit many children with hearing loss, those with limited residual hearing frequently require better access to sound than even the best hearing aids can provide in order to acquire age-appropriate lexical skills. A CI is a device that provides direct stimulation to the auditory nerve, thereby maximizing access to sound. This access to sound has proven results in better outcomes for spoken language development in these children, as compared to children with similar levels of hearing loss who use hearing aids (Tye-Murray, 2009). Cochlear Implants and Spoken Language Outcomes There is ample evidence that shows the benefits of CIs over hearing aids for children with severe to profound hearing loss. It is less clear, however, as to the level of spoken language outcomes for children who use CIs compared to children with typical hearing. Research suggests there are a variety of potentially important factors impacting the development of spoken language in children who use CIs. These include age-of-implantation, type and amount 30

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of early intervention, nonverbal cognitive skills, SES, gender, type and duration of device use, and communication method (Ching et al., 2009; Colletti, 2009; Connor, Craig, Raudenbush, Heavner, & Zwolan, 2006; Dettman et al., 2004; Forli et al., 2011; Geers, Moog, Biedenstein, Brenner, & Hayes, 2009; Hayes, Geers, Treiman, & Moog, 2009; Holt & Svirsky, 2008; Manrique, Cervera-Paz, Huarte, & Molina, 2004; Miyamoto, Hay-McCutcheon, Kirk, Houson, & Bergeson-Dana, 2008; Nicholas & Geers, 2007). In studies that compared spoken language skills of children who use CIs to children with typical hearing, group mean scores on measures of vocabulary, receptive, and/or expressive language showed that earlier implantation (receiving a CI within the first or second year of life) significantly improved outcomes (Ching et al., 2009; Colletti, 2009; Connor et al., 2006; Geers et al., 2009; Hayes et al., 2009; Holt & Svirsky, 2008; Manrique et al., 2004; Nicholas & Geers, 2007). In some cases, outcomes reached levels commensurate or nearly commensurate with children with typical hearing (Ching et al., 2009; Colletti, 2009; Connor et al., 2006; Hayes et al., 2009). In contrast, some children receiving CIs early in life continued to demonstrate spoken language skills significantly below the average range, even after several years of CI use (Geers et al., 2009; Holt & Svirsky, 2008; Manrique et al., 2004). For all of these studies, participants demonstrated wide ranges of individual variability in outcomes. In a systematic review of the clinical efficacy of CIs, Forli and colleagues (2011) investigated the evidence regarding the effects of age-of-implantation, binaural/bimodal stimulation, and outcomes in children with additional disabilities. Included studies had to meet the following requirements: be peer-reviewed, be published between 2000 and 2010, involve pediatric samples of children with CIs (from infancy through adolescence), and focus on the evaluation of verbal perception, spoken language comprehension, and/or spoken language production. In addition, studies had to meet criteria for rigor in methodology and utility of design in relation to the research questions. Of 929 located articles, 49 met the criteria for full review. Existing evidence supported the benefits of early cochlear implantation, specifically converging around 18 months of age. However, the authors noted that there were few studies involving children receiving CIs under 12 months of age. ‘Younger’ was also variably defined among studies. Studies on the benefits of device use (unilateral vs. bilateral CI or bimodal stimulation) revealed a wide range of individual outcomes, but showed advantages of bilateral and bimodal over unilateral CIs for sound localization and listening in both noisy and quiet environments. Evidence further showed that children who use CIs and who have additional disabilities demonstrated improved communication outcomes, though not to the level of those without additional disabilities. Effect of Cochlear Implants on Lexical Language

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Nonverbal Cognitive Skills and Age-of-Implantation Nonverbal cognitive skills appear to be an important confounding factor in the research on language development in children who use CIs. In their study of 153 children who use CIs between the ages of 4.11 and 6.11 years, Geers and colleagues (2009) found that less than half demonstrated spoken language outcomes in the average range when compared to children with typical hearing. Nonverbal cognitive skills accounted for the most variance in these outcomes, followed by SES level, gender, and age-of-implantation. Children with higher nonverbal cognitive skills scored better on all language outcomes (vocabulary, receptive, and expressive language). The authors noted that inclusion of children with IQ scores below the average range likely impacted overall results. In a different study of 76 children who use CIs, Nicholas & Geers (2007) controlled for nonverbal cognitive skills. Spoken language outcomes, measured at 3.5 years and again at 4.5 years, were compared to two groups of children with typical hearing, matched by age. When nonverbal cognitive skills were controlled, age-of-implantation significantly predicted spoken language outcomes. Children who received CIs by 12–13 months of age achieved scores within the average range on standardized measures of receptive vocabulary and receptive and expressive language at 4.5 years of age. Children receiving CIs at later ages did not reach average levels. Hayes and colleagues (2009) investigated receptive vocabulary outcomes in a sample of 65 children who received CIs before 5 years of age, were enrolled in an intensive listening and spoken language program, and who had cognitive skills in the average range. Age-of-implantation again was a significant predictor of spoken language outcomes. Children receiving CIs by 12 months of age reached average vocabulary levels after 2.5 years of CI use, while those receiving CIs by 24 months of age required 4 years of use to reach the same levels. Children receiving CIs at 3 and 4 years old did not attain average vocabulary levels even after 6 years of CI use. However, the year-ofimplantation for participants ranged from 1991 to 2004, and there was a moderate, significant correlation between year-of-implantation and age-ofimplantation. Further examination of that relationship showed that children with a later year-of-implantation demonstrated significantly better initial vocabulary scores, but only those with early age-of-implantation (1–2 years of age) achieved vocabulary levels within the average range of children with typical hearing. Summary Lexical development is a critical component of spoken language and later literacy development. Studies of lexical development in children who use CIs show mixed results, with some children reaching age-appropriate levels while 32

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others experience significant delays. Nonverbal cognitive skills and age-ofimplantation are shown to be significant and apparently covaried predictors of spoken language outcomes in this population.

Present Study The present study investigated receptive and expressive vocabulary skills in a small sample of preschool children who use CIs, were developing spoken language, and were enrolled in their first or second year of preschool. It was designed to address the following questions: (1) How do these children’s spoken vocabulary skills compare to established norms for children with typical hearing who are the same age?; and (2) How do their spoken vocabulary skills compare to a sample of children with typical hearing when age and nonverbal IQ are controlled?

Method Participants Subjects in each group were between 43 and 77 months of age. The mean age for children who use CIs was 59.4 months (4.95 years) and for children with typical hearing was 58.3 months (4.86 years). The two groups were similar for SES, ethnicity, and gender. Subjects were assessed during the spring of their first or second year in preschool. The researchers received approval from their institutional review board. Subject participation was determined through parental consent. Subject demographics for both groups appear in Table 1. Cochlear Implant Group Children who use CIs were selected from children in an established Auditory-Oral Education Center (the Center) for children with hearing loss, located in a suburban area in the Northeast. The listening and spoken language approach focuses on development of listening and speaking without use of manual communication (Tye-Murray, 2009). Consistent use of technology is also a strong component of this approach. Of the 17 children attending the Center, parental permission to participate was granted for 9 children (6 boys and 3 girls). All of these children scored in the average range on the Wechsler Non-Verbal Scale of Ability (WNV) and were included in the study. The average age of hearing loss identification for this group was 8.8 months, and all participants were identified prior to their second birthday (range from 0–23 months). Participants wore hearing aids for an average of 6.1 months prior to receiving a CI. Age-of-implantation ranged from 12–30 months of age, with a mean age of 19.2 months. At the time of their first CI, all children met currently accepted criteria for implantation: (a) bilateral profound sensorineural hearing Effect of Cochlear Implants on Lexical Language

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Table 1. Demographic data Typical Hearing Total N 42 Male 20 Female 22 Age at testing M 58.3 Range 53–66 Age diagnosed M – Range – Time hearing aids worn pre-implant M – Range – Age-of-implantation M – Range –

Cochlear Implant 9 6 3 59.4 43–77 8.8 0–23 6.1 1–11 19.2 12–30

Note. Ages and time in months.

loss, (b) lack of auditory skills development, (c) limited benefit from appropriately fit hearing aids, (d) no physical contraindications for placement of the CI, (e) no medical contraindications, (f) medical clearance to undergo surgery, (g) no contraindicating psychiatric or organic disabilities, (h) enrollment in an aural (re)habilitation intervention that emphasizes developing listening skills, and (i) realistic expectations and commitment to follow-up appointments (Thedinger, 1996; Tye-Murray, 2009). Six of the participants used bilateral CIs, and the age range for the second implant was 50–60 months of age. Typical Hearing Group Forty-two preschool children with typical hearing from two universal Pre-K classrooms in a Northeastern rural public school district were included as the control group. Seven in this group scored below 85 (- 1 SD) on the WNV and were counted in the study. Possible effects due to cognitive ability were controlled for by entering WNV as a covariate in an analysis of covariance (ANCOVA). All participants with typical hearing also scored within normal limits on their latest hearing screening completed in school, and showed no history of hearing problems in their school health records. Site Descriptions The Center is a small, private suburban school for children with hearing loss. The Center uses a listening and spoken language approach to prepare students, ages birth to 6 years old, for eventual transition into mainstream public or 34

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private schools. Preschool children attend school 5 days a week in small classes of approximately six to eight students. Each class has at least one teacher of the deaf to provide academic instruction. The rooms are designed to meet the unique acoustic needs of the children and include wall-to-wall carpeting, acoustic ceiling tiles, wall coverings, and ceilings mounted with soundfield FM systems. Many children also use personal FM systems. Children receive daily 30-minute individual speech-language therapy sessions, conducted by a certified and licensed speech-language pathologist. Early literacy and numeracy, writing, science, music, art, fine/gross motor, and play time are provided through the same curriculum approved by the state education department and utilized in general education programs across the state. The public school universal Pre-K program is offered in two elementary schools, 5 days a week. Development in gross and fine motor skills, reading and vocabulary skills, writing, math, and social and emotional growth are addressed through a teacher-directed and child-selected fashion and in accordance with the State Education Department curriculum. Lexical Language Measures The Peabody Picture Vocabulary Test–4th Edition (PPVT-4) is a normreferenced measure designed to assess receptive vocabulary in individuals age 2 years, 6 months, through 90 years old. The PPVT-4 was recently updated to include items that broadly sample words representing 20 content areas and parts of speech across all levels of difficulty, and has received wide support as a measure of receptive vocabulary (Dunn & Dunn, 2007). The Expressive Vocabulary Test–2nd Edition (EVT-2) is also a norm-referenced measure, recently updated and designed to assess expressive vocabulary for individuals age 2 years, 6 months, through 90 years old (Williams, 2007). For ease in comparing expressive and receptive vocabulary skills, the EVT-2 and the PPVT-4 were co-normed on the same population. The norming sample included over 3,500 individuals, matching the current U.S. population along parameters of gender, race/ethnicity, geographic region, socioeconomic status, and clinical diagnosis or special-education placement. The co-norming of these tests allows direct comparison of the two tests’ scales. Included in the norming sample are individuals with Attention Deficit Hyperactivity Disorder (ADHD), Emotional/Behavioral Disturbance, Language Delay, Language Disorder, Learning Disability, Mental Disability, and Speech Impairment. Both assessments are individually administered and take between 10 and 20 minutes. For the PPVT-4, the respondent must select the picture from a field of four that best represents the meaning of the stimulus word presented orally by the examiner. For the EVT-2, the respondent must provide a verbal response when the examiner presents a picture and asks a question about it (e.g., ‘‘What color is this?’’; ‘‘What is the ___ doing?’’; ‘‘What is this?’’). Testing for both Effect of Cochlear Implants on Lexical Language

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Table 2. Language performance: Children with typical hearing versus children who use cochlear implants, with control for cognitive ability

PPVT-4 EVT-2

Typical Hearing n ¼ 42; M (SD)

Cochlear Implant n ¼ 9; M (SD)

g2

Sig.

Observed Power

102.95 (14.55) 105.05 (12.28)

96.0 (15.46) 105.0 (16.87)

.072 .004

.060 .672

.471 .070

Note. Test conducted using ANCOVA. For g2 0.0099 ¼ small effect, 0.0588 ¼ medium effect, and 0.1379 ¼ large effect (Cohen, 1988).

assessments continues until the respondent reaches a specified level of error. Assessment results for the PPVT-4 and EVT-2 are summarized in Table 2. Cognitive Measure The WNV is a norm-referenced, individually administered clinical instrument designed to assess the general cognitive ability in individuals age 4 years, 0 months, through 21 years, 11 months. The WNV was normed on a stratified sample of 1,323 individuals in the United States. The sample was selected to reflect the data gathered by the 2000 U.S. Census. Demographics reflect stratification along the variables of age, gender, race/ethnicity, education level, and geographic region (Wechsler & Naglieri, 2006). This assessment tool was specifically chosen for the current study because its normative sample included children who were deaf and children who were hard of hearing (Wechsler & Naglieri, 2006). Hearing loss was either unilateral or bilateral, and greater than or equal to 55 dB. More specifically, individuals in the deaf group included children who use CIs. These individuals were developing spoken language, had attended an auditory-verbal school, or were postlingually deafened. The performance of these special populations showed negligible effect sizes when compared to matched controls (Mhh ¼ 96.0, SD ¼ 15.3; Md ¼ 103.0, SD ¼ 10.3; Mc ¼ 100.4, SD ¼ 15.2), supporting its use as a measure of cognitive ability for individuals who are deaf or hard of hearing (Wechsler & Naglieri, 2006). The WNV is individually administered and takes between 10 and 20 minutes to administer to the youngest age group, ages 4 years through 7 years, 11 months. The brief battery used for this study includes the Matrixes and Recognition subtests. Reliability coefficients on the individual Matrixes and Recognition subtests (r¼.78 – .89) and for the total brief battery (r¼.87 – .88) for participants ages 4–5 years indicate acceptable reliability. The Matrixes subtest involves completing a pattern using shapes and colors, and correlates with general ability, perceptual reasoning ability, and simultaneous processing. Recognition involves viewing a simple stimulus for 3 seconds and then 36

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matching it to a response option, and is linked with immediate memory and general ability (Wechsler & Naglieri, 2006). Procedure The investigator collaborated with the directors of the preschool programs to identify children who were eligible to participate in the study. Children were identified based on a review of their cumulative file and parental consent. Medical information was provided to the examiner regarding CIs. Potential participants with typical hearing were eligible with the following criteria: a standard score of 70 or higher on the WNV, testing within normal limits on the most recent annual school hearing exam within normal limits, and parental permission. Medical information and information regarding time in school was obtained by examining school records and by report of school professionals at both sites. For children with hearing loss, information about age-ofimplantation and degree of hearing loss were obtained through school records and by report of school professionals at the Center. Parental consent for all children was obtained by mailing out a packet, which contained a description of the study and details regarding confidentiality. Two advanced graduate students in school psychology were trained to assist in the assessment of the subjects. The actual assessments were conducted in a small office with minimal distractions in the children’s school building by either the investigator or by one of two trained graduate students. The WNV was administered first, followed sequentially by the PPVT-4 and EVT-2. All tests were administered and scored using standardized procedures.

Results Table 2 reports the mean standard scores and standard deviations for the CI and control groups. Both groups demonstrated lexical skill levels comparable to the total normative sample for same age-range children (3.6 – 5.11) for these co-normed instruments (n ¼ 520, M ¼ 100, SD ¼ 15). The difference of the expected standard score from the nonclinical reference group for children with CIs (n ¼ 46) on the PPVT-4 is 29.7 and on the EVT-2 is 22.5. For children with hearing loss who don’t have CIs and were therefore assumed to have less severe hearing loss (n ¼ 53), the expected difference in standard scores on the PPVT-4 is 17.3 (Dunn & Dunn, 2007) and on the EVT-2 is 11.1 (Williams, 2007). Upon initial examination, the CI group appears to have exceeded these published expectations, comparing favorably to both the normative sample and the control group. To determine whether significant differences existed for expressive or receptive vocabulary, two ANCOVAs were conducted for EVT-2 and PPVT-4 scores comparing control and CI groups with cognitive entered as a covariate. Levene’s (1960) test of equality of error variance for EVT-2 (p¼ .067) and PPVT-4 Effect of Cochlear Implants on Lexical Language

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(p ¼ .679) was nonsignificant for heterogeneity of variance, indicating that, even with the unequal sample sizes, the assumption of homogeneity of variance was not violated. Therefore, comparison of unequal sample sizes can be supported. The results were nonsignificant for EVT-2, F(1, 51)¼.181, p¼.672 and for PPVT-4, F(1, 51) ¼ 3.71, p ¼ .060, indicating no difference between the control and CI groups, with cognitive ability included (see Table 2). The nearly identical EVT-2 results produced a small effect size, g2 , .0099 (see Cohen, 1988, p. 283), indicating that it is unlikely a larger CI sample would result in a significant difference in expressive vocabulary performance. However, the PPVT-4 results, with low observed power¼.471 and a medium effect size, g2 ¼.072, suggest that a larger CI sample with a difference of a similar magnitude may reach significance. Cognitive ability was not significant for EVT-2. For PPVT-4, F(1, 51) ¼ 5.55, p ¼ .024, 10.2% of variance was explained by cognitive ability.

Discussion The present study compared outcomes of a small group of preschool children who use CIs to established norms for children with typical hearing on standardized measures of vocabulary, and to a participant group of children with typical hearing. Participants were matched for gender and age, and nonverbal cognitive skills were controlled. Findings indicated that this group of children who use CIs demonstrated both receptive and expressive vocabulary skills within the average range as compared to peers and established norms. Though the sample was small, the investigators believe this study contributes to the evidence on spoken language outcomes for children who use CIs. The existing evidence shows widely varying outcomes in vocabulary achievement for young children who use CIs. Some of this variability likely occurs as a result of uncontrolled confounding variables (i.e., nonverbal cognitive skills and age-of-implantation). For the present sample, the average age-of-implantation was 19.2 months, with a range of 12–30 months (see Table 1). While some evidence indicates that preschool children in this age range who receive a CI demonstrate vocabulary skills well below average (Ching et al., 2009; Colletti, 2009; Nicholas & Geers, 2007), the children in the present sample achieved outcomes in the average range. Results are consistent with Hayes and colleagues (2009), who found that children who receive CIs by age 24 months can achieve vocabulary skills commensurate to peers with typical hearing after only a few years of CI use. It is interesting to note that the present sample’s characteristics were more similar to the latter study’s sample. Both included children immersed in listening and spoken language programs, with nonverbal cognitive skills in the average range, and who rely only on spoken language communication. These particular variables may explain some of the differences from other studies showing lower outcomes. For example, the sample used by Nicholas & Geers (2007) 38

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included children with cognitive skills as much as - 2 SD below the mean. As noted by those authors, this was a likely factor in the overall lower spoken language scores of their sample. In addition, 6 of the 9 participants in the present sample received bilateral CIs. Binaural implantation has been shown to significantly improve listening skills for young children (Forli et al., 2010), and may have contributed to better outcomes. The present study contains some significant limitations. First and foremost, the small sample size limits generalization of outcomes. However, results of statistical analyses suggest that the study’s design met required assumptions for analysis. A second limitation involves selected outcomes. Spoken language outcomes for this study were limited to vocabulary. Some studies indicate that children tend to perform better on vocabulary tasks than more complex language skills (i.e., comprehension and use of grammar and syntax) (Ching et al., 2009; Holt & Svirsky, 2008; Manrique et al., 2004). Additional investigation of more complex language tasks is therefore warranted to determine if overall language skills for this group are consistent with its vocabulary outcomes. Third, the present sample was relatively homogenous in that all children who use CIs demonstrated nonverbal cognitive skills within the average range, attended the same intensive listening and spoken language program, and communicated only through spoken language. Therefore, no generalization of results could be made to other types of programs, even given a larger sample size. However, there is value for investigation of such homogenous groups. Since educational programs can have significant impact on language outcomes and academic achievement, it is an important issue for research. Hayes and colleagues (2009) noted similar composition of their sample and suggested that such investigation may be used as baseline information to compare against other educational programs. Practical Applications Research in the field of cochlear implantation is shifting. Children with hearing loss are being identified at much younger ages and those needing CIs are now receiving them as young as 12 months of age (Tye-Murray, 2009). These changes broaden the need for additional research with infants, toddlers, and preschoolers. This also suggests the need for widespread education of community service agents who work with children. It is likely that as technology continues to improve and the choice to obtain CIs becomes increasingly available to younger children, community service providers will have more and more contact with children who use CIs. Implications for Schools The implications for schools are evident. Most importantly, schools should be prepared to work with children using CIs. The Center in this study prepares Effect of Cochlear Implants on Lexical Language

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preschool children with hearing loss to enter mainstream educational settings. At transition, the mainstream or general education setting acquires the responsibility for the day-to-day management of technology, supports and accommodations, special and related services, and the interface with the child’s audiologist. The technology provides access to sound but it does not change the fact that the child is deaf. Though early identification and implantation open the door to greater spoken language proficiency, school personnel must be prepared to provide the appropriate environment, education, and supports for academic success. School systems can support professional preparedness through continuing education activities that promote knowledge and skills of spoken language development in children with hearing loss. In addition, higher education programs should ensure that principles, methods and practices supporting development of spoken language are incorporated into the curriculum for teachers of the deaf and speech-language pathologists.

References Bowyer-Crane, C., Snowling, M. J., Duff, F. J., Fieldsend, E., Carroll, J. M., Miles, J.,. . .Hulme, C. (2008). Improving early language and literacy skills: Differential effects of an oral language versus a phonology with reading intervention. Journal of Child Psychology and Psychiatry, 49(4), 422–432. Ching, T. Y., Dillon, H., Day, J., Crow, K., Close, L., Chisholm, K., & Hopkins, T. (2009). Early language outcomes of children with cochlear implants: Interim findings of the NAL study on longitudinal outcomes of children with hearing impairment. Cochlear Implants International, 10(S1), 28–32. Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Lawrence Erlbaum. Colletti, L. (2009). Long-term follow-up of infants (4–11 months) fitted with cochlear implants. Acta-Otolaryngologica, 129, 361–366. Connor, C., Craig, H., Raudenbush, S., Heavner, K., & Zwolan, T. (2006). The age at which young deaf children receive cochlear implants and their vocabulary and speech-production growth: Is there an added value for early implantation? Ear and Hearing, 27, 628–644. Dettman, S. J., Fiket, H., Dowell, R. C., Charlton, M., Williams, S. S., Tomov, A. M., & Barker, E. J. (2004). Speech perception results for children using cochlear implants who have additional needs. The Volta Review, 104(4), 361– 392. Dunn, L. M., & Dunn, D. M. (2007). Peabody picture vocabulary test, fourth edition, manual. San Antonio, TX: Pearson Education. Forli, F., Arslan, E., Bellelli, S., Burdo, S., Mancini, P., Martini, A.,. . .Berrettini, S. (2011). Systematic review of the literature on the clinical effectiveness of the cochlear implant procedure in paediatric patients. Acta Otorhinolaryngologica Italica, 31, 281–298. 40

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Geers, A. E., Moog, J. S., Biedenstein, J., Brenner, C., & Hayes, H. (2009). Spoken language scores of children using cochlear implants compared to hearing age-mates at school entry. Journal of Deaf Studies and Deaf Education, 14(3), 371–385. Harlaar, N., Hayiou-Thomas, M. E., Dale, P. S., & Plomin, R. (2008). Why do preschool language abilities correlate with later reading? Journal of Speech, Language, Hearing Research, 51, 688–705. Hayes, H., Geers, A., Treiman, R., & Moog, J. (2009). Receptive vocabulary development in deaf children with cochlear implants: Achievement in an intensive auditory-oral educational setting. Ear and Hearing, 30(1), 128–135. Hoff, E. (2009). Language development (4th ed.). Stamford, CT: Wadsworth Cengage Learning. Holt, R. F., & Svirsky, M. A. (2008). An exploratory look at pediatric cochlear implantation: Is earliest always best? Ear & Hearing, 29, 492–511. Levene, H. (1960). Robust tests for the equality of variance. In I. Olkin, (Ed.), Contributions to Probability in Statistics, pp. 278–292. Palo-Alto, CA: Stanford University Press. Manrique, M., Cervera-Paz, F. J., Huarte, A., & Molina, M. (2004). Advantages of cochlear implantation in prelingual deaf children before 2 years of age when compared with later implantation. The Laryngoscope, 114, 1462–1469. Miyamoto, R. T., Hay-McCutcheon, M. J., Kirk, K. I., Houston, D. M., & Bergeson-Dana, T. (2008). Language skills of profoundly deaf children who received cochlear implants under 12 months of age: A preliminary study. Acta Oto-Laryngologica 128, 373–377. Muter, V., Hulme, C., Snowling, M. J., & Stevenson, J. (2004). Phonemes, rimes, vocabulary and grammatical skills as foundations of early reading development: Evidence from a longitudinal study. Developmental Psychology, 40(5), 665–681. Nicholas, J G., & Geers, A. (2007). Will they catch up? The role of age at cochlear implantation in the spoken language development in children with severe to profound hearing loss. Journal of Speech, Language, and Hearing Research, 50, 1048–1062. Owens, R. E. (2008). Language development: An introduction (7th ed.). Boston: Pearson Education, Inc. Rescorla, L. (2005). Age 13 language and reading outcomes in late-talking toddlers. Journal of Speech, Language, and Hearing Research, 48, 459–472. Shanahan, T. (2006). The national reading panel report: Practical advice for teachers. Naperville, IL: Learning Point Associates/North Central Regional Educational Laboratory. (ERIC Document Reproduction Service No. ED489535.) Thedinger, B. S. (1996). Cochlear implants. In J. L. Northern (Ed.), Hearing Disorders (pp. 291–298). Boston: Allyn and Bacon. Tye-Murray, N. (2009). Foundations of aural rehabilitation, 3rd edition. Albany, NY: Delmar Cengage Learning. Effect of Cochlear Implants on Lexical Language

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Wechsler, D., & Naglieri, J. A. (2006). Wechsler nonverbal scale of ability, technical and interpretive manual. San Antonio, TX: Pearson Education. Williams, K. T. (2007). Expressive vocabulary test, 2nd edition, manual. San Antonio, TX: Pearson Education.

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The Volta Review, Volume 113(1), Spring 2013, 43–56

A Survey of Assessment Tools Used by LSLS Certified Auditory-Verbal Therapists for Children Ages Birth to 3 Years Old Deirdre Neuss, Ph.D., LSLS Cert. AVT; Elizabeth Fitzpatrick, Ph.D., LSLS Cert. AVT; Andre´ e Durieux-Smith, Ph.D.; Janet Olds, Ph.D.; Katherine Moreau, M.A., Ph.D.; Lee-Anne Ufholz, MLIS; JoAnne Whittingham, M.Sc.; and David Schramm, M.D. Infants 12 months of age or older who have a severe to profound hearing loss frequently receive cochlear implants. Given the inherent challenges of assessing children of this age, this study aims to determine how Listening and Spoken Language Specialists Certified Auditory-Verbal Therapists (LSLS Cert. AVTe) gauge the progress of very young children who use cochlear implants. A survey of LSLS Cert. AVTs was conducted to determine how they assess the progress of young children ages 1 to 3 years old. Respondents indicated that the most commonly used Deirdre Neuss, Ph.D., LSLS Cert. AVT, is an auditory-verbal therapist at the Children’s Hospital of Eastern Ontario and a clinical investigator at the Children’s Hospital of Eastern Ontario Research Institute. Elizabeth Fitzpatrick, Ph.D., LSLS Cert. AVT, is an Associate Professor in the Faculty of Health Sciences at the University of Ottawa and a clinical investigator at the Children’s Hospital of Eastern Ontario Research Institute. Andr´ee Durieux-Smith, Ph.D., is a Professor Emeritus in the Faculty of Health Sciences at the University of Ottawa and Scientific Director of the Research Institute at the Montfort Hospital. Janet Olds, Ph.D., is a Neuropsychologist at the Children’s Hospital of Eastern Ontario and an clinical investigator at the Children’s Hospital of Eastern Ontario Research Institute. Katherine Moreau, Ph.D., is an Associate Scientist at the Children’s Hospital of Eastern Ontario Research Institute. Lee-Anne Ufholz, MLIS, is the Director of the Health Sciences Library in the Faculty of Health Sciences at the University of Ottawa. JoAnne Whittingham, M.Sc., is the Audiology Research Coordinator at the Children’s Hospital of Eastern Ontario Research Institute. David Schramm, M.D., is an Associate Professor in the Department of Otolaryngology at the University of Ottawa and a clinical investigator at the Children’s Hospital of Eastern Ontario Research Institute. Correspondence concerning this manuscript may be addressed to Dr. Neuss at dneuss@ cheo.on.ca. Assessment Tools Used by LSLS Cert. AVTs

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methods of gauging progress in children with hearing loss were: checklists, normreferenced tests, consultation of scales of typical development, observation, parent report, videotaping, and language sampling. As using checklists is a longstanding practice of listening and spoken language professionals, the survey focused on which checklists are most commonly used as well as the perceived strengths and weaknesses of these assessment tools. Findings indicate that 70% of respondents use checklists regularly for a variety of reasons, including coaching parents, developing goals, and monitoring progress. It is noteworthy that 29.3 % of respondents commented on the ease of checklist use. Despite their widespread use, respondents expressed concerns about the lack of clarity and comprehensiveness of the checklists presently available.

Introduction Early identification of hearing loss through universal newborn hearing screening programs and early access to sound has fundamentally altered expectations for children with hearing loss (Cole & Flexer, 2011; Estabrooks, 2006). The cochlear implant has become the technology of choice for those who do not receive sufficient benefit from hearing aids (Beiter & Estabrooks, 2006). Infants with severe to profound hearing loss who are 12 months of age or older frequently receive cochlear implants (Dettman, Pinder, Briggs, Dowell, & Leigh, 2007). Professionals and parents widely recognize that children who receive cochlear implants require intensive intervention to attain optimal benefits from the device (Cole & Flexer, 2011; Nicholas & Geers, 2008). Auditory-verbal therapy has gained widespread recognition as an intervention approach that optimizes the child’s ability to access sound (Estabrooks, 2006). The aim of this therapy is to coach parents in developing their child’s listening and spoken language by using access to the acoustic signal provided by a hearing aid and/or cochlear implant (Hogan, Stokes, White, Tyszkiewicz, & Woolgar, 2008). This approach emphasizes early auditory stimulation, the use of technology, specialized therapeutic techniques, and parent-focused intervention (Estabrooks, 2006; Wu & Brown, 2004). A long-standing practice in auditory-verbal therapy has been to use checklists developed for clinical use (see Estabrooks, 1998, and Simser, 1993, for examples of checklists). Checklists are tools professionals use when assessing communication skills in children. They have been informed by the normal sequence of communication development in children with typical hearing and by the developers’ knowledge of the acoustic properties of speech. These assessments typically include lists of discrete skills in listening, speech, and language development. Several authors have described the utility of these checklists for goal-setting and guiding treatment (Estabrooks, 1998; Pollack, Goldberg, & Caleffe-Schenck, 1997; Simser, 1993). A potential limitation of these checklists is that many were developed for use with children prior to the availability of cochlear implants. Cochlear implant 44

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technology allows children to access sound and develop listening skills earlier and quicker than previous generations of children with severe to profound hearing loss, who had only limited acoustic cues obtained from hearing aids (Nicholas & Geers, 2008). Consequently, current checklists may be of limited value when used with children who have received cochlear implants early in life. The authors of this paper conducted a survey to determine how Listening and Spoken Language Specialists (LSLSe) Certified Auditory-Verbal Therapists (LSLS Cert. AVTe) assess the progress of young children who receive cochlear implants by 12 months of age. In addition, the survey examined which checklists are commonly used. Objectives of the survey were to: (1) Determine the methods used by LSLS Cert. AVTs to gauge progress in young children with cochlear implants. (2) Identify a list of checklists used by LSLS Cert. AVTs to guide them in assessing listening, speech, and language in young children. (3) Determine the information LSLS Cert. AVTs gained from checklists, and identify the strengths and weaknesses of checklists.

Method Participants and Recruitment The authors obtained a list of all LSLS Cert. AVTs who provide service in English from the directory of the AG Bell Academy for Listening and Spoken Language, the certifying body for LSLS professionals. All 275 English-speaking LSLS Cert. AVTs listed in the directory at the time of the study, in 2008, were invited to participate. The study was approved by the Research Ethics Board of the Children’s Hospital of Eastern Ontario. Instrument Development and Procedures The primary purpose of this research was to learn how LSLS Cert. AVTs gauge progress in young children with hearing loss, and specifically how they use checklists. A survey was developed to collect information on the following areas: methods used to gauge progress and set goals for children with hearing loss; specific checklists used with children under 3 years of age who have cochlear implants; and therapists’ views of checklists, including their strengths and weaknesses. In addition, participant demographics including the number of years of practice, sources of program funding, and ages of children served were collected. The respondents’ names were anonymous to the researchers. The survey questions are provided in Appendix A. Assessment Tools Used by LSLS Cert. AVTs

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Table 1. The international distribution of questionnaire invitations and responses Country of Practice United States of America Canada Australia New Zealand Singapore United Kingdom China Taiwan Argentina India Israel Mexico Paraguay Philippines Switzerland TOTAL

Number of Participants who Received the Questionnaire 170 55 26 7 3 3 2 2 1 1 1 1 1 1 1 275

Number of Participants Responding 62 30 16 3

(36.5%) (54.5%) (61.5%) (42.8%) 1 1 1

1 116

The questionnaire consisted of 17 items and was peer-reviewed by two LSLS Cert. AVTs for clarity before being circulated. Information letters and surveys were sent to the 275 potential participants by email. Using a modified version of the Tailored Design Method (Dillman, 2000), two electronic reminder letters were subsequently sent. Data Analysis Analyses consisted primarily of calculating descriptive statistics using SPSS version 18.0 (SPSS Inc., Chicago IL). Analyses also determined the frequency with which respondents use the various checklists. Open-ended responses on the surveys were analyzed qualitatively. Two researchers independently identified key terms, which were tabulated to determine frequency of occurrence.

Results Characteristics of Participants Of the 275 surveys sent, 117 (42.2%) were returned; however, one questionnaire was not completed leaving 116 surveys to be fully analyzed. The mean number of years of practice of the respondents was 15.3 (SD ¼ 8.2) with a range of 3 to 40 years. As shown in Table 1, 95.7% of participants practiced in four countries: United States, Canada, Australia, and New 46

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Table 2. The characteristics of programs reported by participants N (Percentage) Country of Practice USA Canada Australia New Zealand Other Current Work Setting Private Clinic/Practice School Based Hospital NGO/Nonprofit Other Funding Public Funds Public/Private Private Practice/Institutions Public Charitable Percentage of Caseload 0 to 3 years of age More than 25% Less than 25%

62 30 16 3 5

(53.4%) (25.9%) (13.8%) (2.6%) (4.3%)

52 24 19 16 5

(44.8%) (20.7%) (16.4%) (13.8%) (4.3%)

39 35 30 12

(33.6%) (30.2%) (25.9%) (10.3%)

81 (69.8%) 35 (30.2%)

Zealand. The response rate was representative of the international distribution of LSLS Cert. AVTs in the AG Bell Academy registry at the time of this survey. As shown in Table 2, listening and spoken language services are provided under a wide variety of funding arrangements. Respondents listed private clinics/practice most frequently (44.8%) as their place of work. In addition, 74.1% reported work settings that involve some public funding. Work setting and funding arrangements were considered relevant topics to address as these issues can affect what services are provided to children, and therefore influence the responses. A total of 81 respondents (69.8%) reported that over 25% of their current caseloads included children in the birth to age 3 range. Thirty-five respondents worked less frequently (less than 25% of their caseload) with children in this age range, and only 3 individuals indicated that they did not currently work with this age group. Current Practices in Assessing Progress in Young Children with Hearing Loss As indicated in Figure 1, LSLS Cert. AVTs use a combination of methods to gauge progress and set goals for young children with hearing loss. The most commonly reported assessment tools were checklists and norm-referenced tests, with checklists being used by 69.7% of therapists. In comparison, 30.2% of respondents reported using scales of typical development to gauge progress. Researchers compared the use of checklists for the 81 respondents who Assessment Tools Used by LSLS Cert. AVTs

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Figure 1. Methods of gauging progress in children with hearing loss.

frequently provided services to children under age 3 (greater than 25% of caseload) to the 32 respondents who followed fewer children in this age group. There was no significant difference in the frequency of use of checklists (p ¼ 0.669). The majority (94.7%) of respondents rated checklists as very useful (64.3%) or somewhat useful (30.4%) in working with children. Figure 1 demonstrates that videotaping and language sampling are each used by less than 5% of therapists. As noted, LSLS Cert. AVTs primarily used norm-referenced tests (61.2%) and checklists (69.0%) to gauge progress for children in the birth to age 3 group. Given that almost 40% of respondents did not report using norm-referenced

Figure 2. Methods of gauging progress in children with cochlear implants.

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Table 3. The top seven checklists as rated by the participants Checklist

Author

N (Percentage)

Development of Auditory Skills Auditory-Verbal Ages and Stages of Development Listening for Littles Checklist of Auditory Communication Skills Cottage Acquisition Scales for Listening, Language & Speech Rossetti Infant-Toddler Language Scale St. Gabriel’s Curriculum for the Development of Audition, Language, Speech and Cognition

(Simser, 1993) (Estabrooks, 1998)

77 (67.0%) 75 (65.2%)

(Sindrey, 1997) (Franz et al., 2004)

70 (60.9%) 43 (37.4%)

(Wilkes, 1999)

31 (27.0%)

(Rossetti, 1990)

18 (15.7%)

(Tuohy et al., 2005)

16 (13.9%)

tests, researchers examined whether there was a relationship between workplace setting and test use. There was no significant difference in the use of norm-referenced tests between therapists working in publicly funded (64.7%) or privately funded (56.7%) settings (p ¼ 0.488). Checklists Used with Children Who Have Cochlear Implants For the subset of children who use cochlear implants, a very similar pattern was observed (Figure 2). Respondents used a variety of methods to monitor spoken language development in children with cochlear implants. A total of 52.6% of respondents reported using checklists with this population. Therapists also reported that consultation with the cochlear implant team helped to determine progress in children (this result is reported in the category referred to as ‘‘other’’ in Figure 2). For children under age 3 who use cochlear implants, 80.2% of respondents used checklists to track progress at least every 6 months. Perspectives on Checklists Used Participants listed 62 different checklists used in current practice, some of which were utilized by only 1 or 2 therapists (Neuss et al., 2009). Table 3 outlines the seven checklists that were utilized by more than 10% of respondents. Several of these tools cover multiple domains of development, including audition, speech, language, and cognition (e.g., St. Gabriel’s Curriculum for the Development of Audition, Language, Speech, and Cognition; Tuohy, Brown, & Mercer-Moseley, 2005), while others focus more specifically on the developAssessment Tools Used by LSLS Cert. AVTs

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Figure 3. Strengths of checklists.

ment of auditory skills (e.g., Checklist of Auditory Communication Skills; Franz, Caleffe-Schenck, & Iler Kirk, 2004). Strengths and Weaknesses of Checklists Participants were asked to describe their views on the strengths and weaknesses of the checklists they used. Responses related to the strengths of these checklists were coded into several categories, as shown in Figure 3. Therapists found them particularly useful for coaching parents, while development of teaching goals and monitoring progress were also seen as valuable features. Nearly one-third (29.3%) of respondents identified the ease of use with young children as a particular strength of checklists. Despite the usefulness of monitoring protocols, 70.2% of participants expressed a lack of confidence in the measures. The lack of clarity and comprehensiveness were noted to be of particular concern. As stated by 1 participant, who indicated that she always uses checklists and finds them very useful, ‘‘They are not standardized in any way—moreover they cannot give you information about whether the amount of progress made is good, O.K., or a cause for concern.’’

Discussion This study aimed to identify the assessment tools used by LSLS Cert. AVTs who work with young children (ages birth to 3 years old) with hearing loss. Through a survey, respondents indicated that they use a range of methods to gauge progress with young children who have hearing loss. Checklists were 50

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reported as the most common method of monitoring progress, with 62 different checklists being identified by the respondents. Although 69.7% of respondents report regularly using checklists and 94.7% find them useful, the majority (70.2%) also expressed concerns regarding their lack of clarity and the inability to draw conclusions about a child’s progress based on checklist results. It is noteworthy that nearly one-third (29.3%) of participants commented on the ease of using checklists, a finding that may account for their widespread application in monitoring progress. Participants mainly reported using checklists for coaching parents, developing goals, and monitoring progress. Other investigators have highlighted that these are important goals when assessing young children (Nicholas & Geers, 2008; Nikolopoulos, Archbold, & Gregory, 2005). The majority of checklists that respondents reported using include auditory behaviors that emerge in young children as they learn to listen. This finding suggests that measures that probe specific auditory skills are considered highly useful in assessing young children developing listening and spoken language. Similar findings were obtained for children with cochlear implants, where respondents also reported using a range of methods, including the extensive use of checklists, to gauge progress. It is noteworthy that the majority of the checklists in use were developed prior to the widespread use of cochlear implants, and that some items may not be entirely applicable in current practice. Limitations One potential limitation of the current study is that participants were provided with four specific examples when asked to identify the checklists they use in their practice. This may have resulted in bias by the inclusion of those checklists at the expense of others. Nonetheless, a total of 62 different measures were identified, which suggests that any bias may have been offset. As with any survey, there is the possibility that questions may be interpreted differently by the respondents than was the intent of the researchers. Although all but 3 respondents worked with young children, 27.6% reported working with a smaller number of children (less than 25% of caseload) in this age range at the time they completed the survey. No information was collected on participants’ previous experience. The respondents practiced primarily in four countries, and therefore represent a range of clinical practices in different geographic areas. This survey was conducted in 2008 and reflects respondent’s experience at that time.

Conclusion This research demonstrates that checklists continue to be widely used by LSLS Cert. AVTs in working with a young population. The results indicate that listening and spoken language professionals apply the information to parent Assessment Tools Used by LSLS Cert. AVTs

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coaching, goal development, and monitoring progress, and value the ease of administration. This research provides an international perspective on the methods used by LSLS Cert. AVTs to monitor children’s listening and spoken language development.

Acknowledgements We would like to thank the Faculty of Health Sciences of the University of Ottawa and the Research Institute of the Children’s Hospital of Eastern Ontario for providing the Partnership Funding Grant for this study. The authors gratefully acknowledge the insightful comments provided by our auditory-verbal therapist colleagues, Erin McSweeney, Kelley Rabjohn, Rosemary Somerville, and Pamela Steacie. Research time provided by the former Director of Operations of the Rehabilitation Patient Service Unit, Lloyd Cowin and Audiology Professional Practice Leader, Linda Moran, allowed the first author the time necessary to complete this project. We want to thank Emma LeBlanc and Erin McSweeney for their contributions to the editing and formatting of this work.

References Beiter, A., & Estabrooks, W. (2006). The cochlear implant and auditory-verbal therapy. In W. Estabrooks (Ed.), Auditory-verbal therapy and practice (pp. 45– 73). Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing. Cole, E. B., & Flexer, C. (2011). Children with hearing loss: Developing listening and talking birth to six (2nd ed.). San Diego, CA: Plural Publishing. Dettman, S. J., Pinder, D., Briggs, R. J., Dowell, R. C., & Leigh, J. R. (2007). Communication development in children who receive the cochlear implant younger than 12 months: Risks versus benefits. Ear and Hearing, 28(Suppl.), 11S–18S. Dillman, D. (2000). Mail and internet surveys: The tailored design method. New York, NY: John Wiley & Sons. Estabrooks, W. (1998). Cochlear implants for kids. Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing. Estabrooks, W. (2006). Auditory-verbal therapy and practice. Washington, DC: Alexander Graham Bell Association for the Deaf and Hard of Hearing. Franz, D. C., Caleffe-Schenck, N., & Iler Kirk, K. (2004). A tool for assessing functional use of audition in children: Results in children with the MED-EL COMBI 40þ cochlear implant system. The Volta Review, 104(3), 175–196. Hogan, S., Stokes, J., White, C., Tyszkiewicz, E., & Woolgar, A. (2008). An evaluation of auditory-verbal therapy using the rate of early language development as an outcome measure. Deafness and Education International, 10(3), 143–167. 52

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Neuss, D., Fitzpatick, E., Durieux-Smith, A., Olds, J., Moreau, K., Pleau, I. A.,. . .Yazdi, F. (2009). Early communication outcomes in infants and toddlers after cochlear implantation: Towards a reliable assessment tool. Poster presented at the 12th Pediatric Cochlear Implantation Conference, Seattle, Washington. Nicholas, J. G., & Geers, A. E. (2008). Expected test scores for preschoolers with a cochlear implant who use spoken language. American Journal of SpeechLanguage Pathology, 17, 121–138. Nikolopoulos, T. P., Archbold, S. M., & Gregory, S. (2005). Young deaf children with hearing aids or cochlear implants: Early assessment package for monitoring progress. International Journal of Pediatric Otorhinolaryngology, 69(2), 175–186. Pollack, D., Goldberg, D., & Caleffe-Schenck, N. (1997). Educational audiology for the limited hearing infant and preschooler (3rd ed.). Springfield, IL: Charles C. Thomas. Rossetti, L. (1990). The Rossetti Infant-Toddler Language Scale. East Moline, IL: LinguiSystems. Simser, J. (1993). Auditory-verbal intervention: Infants and toddlers. The Volta Review, 95(3), 217–229. Sindrey, D. (1997). Listening for littles. London, Ontario: Word Play Productions. Tuohy, J., Brown, J., & Mercer-Moseley, C. (2005). St. Gabriel’s curriculum for the development of audition, language, speech, cognition, early communication, social interaction, fine motor skills, gross motor skills: A guide for professionals working with children who are hearing-impaired (birth to six years) (2nd ed.). Sydney: St. Gabriel’s Auditory-Verbal Early Intervention Centre. Wilkes, E. (1999). Cottage Acquisition Scales of Listening, Language and Speech. San Antonio, TX: Sunshine Cottage School for Deaf Children. Wu, C. D., & Brown, P. M. (2004). Parents’ and teachers’ expectations of auditory-verbal therapy. The Volta Review, 104(1), 5–20.

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Appendix A. Survey 1. How many years have you been in the field of auditory-verbal practice? 2. In what country do you practice? 3. What is your current work setting? (Check all that apply)    

Hospital School Private Clinic Other (please specify)

4. How are your services funded? (check all that apply)    

Public Funds Privately Funded Clinic or Institution Private Practice Other (please specify)

5. How do/did you gauge progress and set goals amongst your 0–3 population? 6. What percentage of your caseload is 0–3 years of age?     

0–25% 26–50% 51–75% 76–100% N/A

7. How often do you use checklists?      

Never Rarely Sometimes Often Always N/A

8. How useful are checklists?    

Very useful Somewhat useful Neutral Not useful

9. What do you see as the strengths of checklists? 10. What do you see as the weaknesses of checklists?

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11. Please indicate each of the checklists that you use/or have used in your auditory verbal practice:     

Development of Auditory Skills (Simser, 1993) Listening for Littles (Sindrey, 1997) Auditory-Verbal Ages and Stages of Development (Estabrooks, 1998) Checklist of Auditory Communication Skills (Franz, Caleffe-Schenck, & Iler Kirk, 2004) Other (please specify)

12. For what purpose do you use checklists?       

Lesson planning/goal setting Gauge progress Diagnosis Prognosis Feedback to parents Feedback to other service providers Other (please specify)

13. I think a checklist that tracks progress on the 0–3 year population of children who use cochlear implants would be useful.     

Strongly disagree Disagree Neutral Agree Strongly agree

14. How do/did you gauge progress and set goals amongst your 0–3 year population of children who use cochlear implants? 15. How frequently would you use a checklist that tracks progress in the 0–3 year population of children who use cochlear implants?       

Daily Weekly Monthly Every six months Annually Never Other (please specify)

16. Would you be willing to participate in the next step of this study? This step will involve a survey that will lead to the development of a preliminary composite checklist.

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17. If you are willing to participate in the next step of this study please provide your contact information:       

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Name: Address: City/Town: Postal Code: Country: Email Address: Phone Number:

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The Volta Review, Volume 113(1), Spring 2013, 57–73

Interactive Silences: Evidence for Strategies to Facilitate Spoken Language in Children with Hearing Loss Ellen A. Rhoades, Ed.S., LSLS Cert. AVT Interactive silences are important strategies that can be implemented by practitioners and parents of children with hearing loss who are learning a spoken language. Types of adult self-controlled pauses and evidence pertaining to the function of those pauses are discussed, followed by a review of advantages to justify implementation of these turn-taking strategies. Practitioners may benefit from selfanalyses to ensure that interactive silences facilitate the process of learning a spoken language in clinical and classroom settings. A call for further evidence is made to determine lengths of deliberate pauses that may be particularly advantageous for young children with hearing loss. This is directly relevant to the optimization of auditory-verbal practice. Suggestions for future study into this topic are also provided. Silences within social interactions are sometimes referred to as deliberate pauses, lack of audible speech, or acoustic silences (Sacks, Schegloff, & Jefferson, 1974). An essential condition of these interactive silences is that they are adult self-controlled pauses, i.e., intervals of time following an adult’s verbal utterance and preceding another verbal utterance by either a child or the same adult (Bruneau, 1973). Interactive silences are multifaceted and complex in their implications and functions (Duez, 1982). For example, silences can structure and regulate interpersonal relationships by serving as critical discourse markers (Maroni, Gnisci, & Pontecorvo, 2008; Saville-Troike, 1995). Some refer to interactive silences as ‘soft’ turn-taking strategies designed to initiate a subsequent response from children, cognitively or affectively, verbally or otherwise Ellen A. Rhoades, Ed.S., LSLS Cert. AVT, is an auditory-verbal consultant and mentor whose services can be accessed through www.AuditoryVerbalTraining.com. Correspondence concerning this article may be directed to Dr. Rhoades at ellenrhoades@ comcast.net. Interactive Silences

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(Ephratt, 2008). Interactive silences can also be a means of maintaining eye contact and establishing an alliance with another person (Ephratt, 2008). Depending on purpose and situational context, adults within similar cultures tend to consciously use interactive silences in slightly different ways and for different durational periods with children (Berger, 2011). However, across dissimilar cultures, people have considerably different perceptions of these silences, particularly in length of deliberate pauses (Roberts, Margutti, & Takano, 2011). For example, people in Japan and China may be more patient with extensive silences whereas Americans tend to minimize them due to feelings of discomfort (Shigemitsu, 2005). A period of silence longer than 1–5 seconds can seem interminably prolonged to many North Americans and Europeans (Vassilopoulos & Konstantinidis, 2012). Typical infant language development is linked with optimum interactive style used by parents (Beckwith & Rodning, 1996; Murray, Johnson, & Peters, 1990). Across the school years, interactive silences seem more important for learning rather than teaching, primarily because they elicit student verbal responses or cognitive processes (Jaworski & Sachdev, 1998). Likewise, selfcontrolled pauses can be considered critical operational strategies integral to the optimal auditory-based intervention for language learning of children and adolescents of all ages. Simply because silence can be a negative experience for some people, it can afford much strength. Rather than considering interactive silences to be problematic (Berger, 2011), practitioners are encouraged to leverage the silence. Some practitioners may find themselves rushing to fill the silent void by answering their own questions or redirecting their questions to another person in the room, whether it be another child or the child’s parent. Some practitioners and parents demonstrate an interactional style that reflects a fast-paced way of talking. Talk flows rapidly, smoothly, and in staccato form, which includes questions not followed with pauses of any significance and where questions are fired off in ‘machine-gun’ style (Tannen, 1981). While this conversational style may work in some cultures, it may not be conducive toward optimizing the language learning process, particularly for children with compromised listening skills. It is critical that practitioners develop sensitivities to the interactional relevance of self-controlled pauses, and understand how these pauses can be modified for optimal use with children and adolescents with hearing loss (Carey-Sargeant & Brown, 2003). Practitioners are encouraged to engage in critical analyses of their own communicative talk, both in classroom and clinical settings (Thornbury, 1996). This assumes, regardless of gender or other background variables, that it is not so much the quantity of talking across activities as the quality of verbal interaction that determines the authenticity of the language learning process (Nunan, 1991; Rowe, 2003; Skinner, Pappas, & Davis, 2005). 58

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A review of publications, including checklists and rating scales for mentoring and evaluating auditory-verbal practitioners, reveals that adult self-controlled pauses tend to be viewed uni-dimensionally, i.e., primarily pausing after asking questions (see Duncan, Kendrick, McGinnis, & Perigoe, 2010; Estabrooks, 2006; Estes, 2010). The varied purposes and types of interactive silences do not yet seem widely recognized. The purpose of this manuscript, then, is to show that judicious use of deliberate silence may provide important evidence-based strategies for auditory-verbal practitioners and parents of children with hearing loss.

Types of Self-Controlled Pauses Deliberate silences exert great power in their meaningfulness. Types of adult self-controlled pauses depend on their placement in an interaction and on continuous or discontinuous conversation, and can be transformed when interpreted differently (Maroni et al., 2008). Interactive silences herein refer to the many types and purposes of adult self-controlled pauses, including waittime, think-time, expectant pause, impact pause, and phrasal intraturn pause. Wait-time, sometimes referred to as the pre-response pause, is accorded the most attention in the following review of aggregate evidence supporting the use of deliberate silence with children. However, this should not be misconstrued as assigning more importance to one type of deliberate pause than another. Wait-Time Questions posed by adults impose a social obligation for children to respond, usually because questions have strong prosodic cues at their ending (Heeman, Lunsford, Selfridge, Black, & van Santen, 2010). The period of time following a question is an operational type of silence commonly referred to as wait-time; this tends to elicit a verbal response to the verbal inquiry. Tobin (1987) defined wait-time as the length of undisturbed time that an adult will wait for a child’s answer to a clear, well-structured question; this pause is also referred to as reaction- or response-time latency. Wait-times permit children increased opportunities to decode the meaning of the direction or question. Rowe (1996) concluded that the length of uninterrupted silence should be at least 3–5 seconds for children with typical hearing. This strategy is now routinely recommended for classroom teachers (Gabel, 2004; Skinner et al., 2005), and school-aged children with typical hearing tend to prefer wait-times of at least 3–5 seconds (Altiere & Duell, 1991; Maroni, 2011; Rowe, 1969, 1974, 1978, 1986). Duration of wait-time is related to the complexity of language in both question and expected response (Maroni et al., 2008). Duration seems dependent on children’s functional language level and context. Waiting as Interactive Silences

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long as 10 seconds may not be appropriate for obtaining a yes/no response or a simple recall of information as some children may need to learn how to respond within an appropriate time frame. Wait-times have a strong relationship with socio-cultural attitudinal factors of traditional or non-westernized worldview (Jegede & Olajide, 1995), hence wait-times are culture-specific (Maroni et al., 2008; Nelson & Harper, 2006). For example, while Asian cultures seem to generally expect longer delays in turntaking, there are differences among Asian countries (Damron & Morman, 2011; Du-Babcock & Tanaka, 2010). Ultimately, all children have different cognitive processing times in that their brains work differently, so wait-times need to be individualized. While correlation does not imply causation, wait-time tends to be associated with positive outcomes, particularly when children need time to make sense of and respond to the demands of complex questions (Brown & Wragg, 1993). Just as advising parents to provide ongoing verbal input is too simplistic a piece of advice, the advice of waiting for a predetermined number of seconds is also too simplistic (Stichter et al., 2009). Duration of wait-time is an important consideration for helping each child complete the linguistic-cognitive tasks required in each situation (Stahl, 1994). Extended wait-times can be effective with children learning English as a second language (Al-Balushi, 2008). Children with auditory processing difficulties and with autism spectrum disorder may also benefit from waittimes considerably longer than the customary 0.9 to 1.5 seconds that special education teachers typically demonstrated (Rowe & Rowe, 2006), possibly because they have slower processing and response times as well as less sensitivity to either the question prosody or the social obligation of questions (Heeman et al., 2010). Hearing loss also influences processing speed (Zekveld, Kramer, & Festen, 2011). Children with hearing loss tend to require longer pause lengths to process linguistic information prior to responding (Carey-Sargeant & Brown, 2003). The need for longer pause lengths seems associated with certain situations, such as that of a noisy academic environment (Towne & Anderson, 1997). Young children have difficulty perceiving speech in noisy environments (Talarico et al., 2007), more so if they have reading difficulties (Inoue, Higashibara, Okazaki, & Maekawa, 2011) or hearing loss (Anderson, 2001). The complexity of the linguistic input can further degrade processing speed; hearing loss is more likely to negatively affect the rapidity of language comprehension when listening conditions are difficult and the vocabulary is more complex. Additionally, some children with hearing loss do not always hear the linguistic input in its entirety; for those children, the process of ‘filling in the missing pieces’ is important (Rhoades, 2011). Finally, age is a critical mediator for the auditory perceptual system to ‘fill in’ what was not heard, a process known as perceptual restoration (see Winstone, Davis, & De Bruyn, 2012). 60

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Given the redundancy of language and a child’s current knowledge base, coupled with contextual cues, time is often needed to figure out which parts were not heard or were misunderstood. Anecdotal reports from auditoryverbal practitioners yield varying opinions as to the length of wait-times, ranging from 10 to 45 seconds (Rhoades, 2011). Some children do not respond even after extensive wait-time. Adults can use this time to decide on an appropriate course of action (Tobin, 1986). For example, some practitioners may choose to rephrase the question, thus giving children another period of uninterrupted time to respond. Other practitioners may opt for a detailed explanation of the initial linguistic unit. Another possible practitioner choice is that of re-directing the question to another person in the room. Still another possible choice is that of answering the practitioner’s own question. Regardless of each adult’s follow-up strategy, wait-time affords both children and adults time to think (Stahl, 1994). Think-Time The post-response pause is referred to as think-time. Brief intentional pauses after children respond to a question may be helpful. This gives the child time to add any further thoughts, minimizing the adult error of ‘jumping in’ when the child hesitates. It also gives time for other children or adults in the room to add any further thoughts, whether they be supportive or contradictory (Stahl, 1994). This additional self-controlled pause can exceed 3–5 seconds (Tobin & Capie, 1983). Expectant Pause The expectant pause, another form of interactive silence, serves as a mild directive prompt (Norris & Hoffman, 1994; Stephenson, Carter, & Arthur-Kelly, 2011). This pause is typically preceded by a prosodic cue, such as the intonation rise at the end of a statement to signal incompleteness (Saville-Troike, 1995). Stephenson and colleagues (2011) found that when a minimum of 5 seconds was incorporated in the length of the expectant pause while teaching students with severe disabilities, opportunities for student participation more than doubled. Expectant pauses tend to involve eye contact, notably a sustained gaze, which serves as an additional cue for turn-taking by subtly encouraging children to vocalize or complete the adult vocalization or to execute the direction (Carey-Sargeant & Brown, 2003). This type of deliberate pause is integral to infant-directed speech (Schaffer, 1996). Expectant pauses are typically preceded by a strategy known as the cloze procedure in which a child completes the adult’s sentence; it is understood that the adult expects a verbal utterance from the child, e.g., ‘‘The three little kittens lost their __.’’ The cloze procedure is very effective for facilitating sustained attention, more frequent turn-taking, greater semantic, and grammatical Interactive Silences

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complexity (Chatel, 2001; Crowe, Norris, & Hoffman, 2000; Lee, 2008). A variation of this strategy occurs when the adult verbalizes a sentence involving a relational tie in which a child is cued to add an element to one previously presented, e.g., ‘‘So they __.’’ Impact Pause The impact pause tends to occur within an extended language-based activity in order to make a point, to grab children’s attention, and to have them wait in anticipation for the next piece of information (Stahl, 1994). This within-speaker type of interactive silence tends to act as a stress marker, permitting children a very brief chunk of time to understand that an important piece of information was just presented, and then to consolidate personal thinking. Serving as a cognitive signal, no requests are made of listeners to provide a verbal response (Stahl, 1994). Phrasal Intraturn Pause The phrasal intraturn pause is another type of within-speaker silence that does not elicit a vocal utterance from anyone (Carey-Sargeant & Brown, 2003). This pause reflects a natural rest in the melody of speech, typically indicating junctures and meaning or grammatical units in spoken language (Berger, 2011; Ephratt, 2008). Children learning a spoken language are more likely to recognize grammatical boundaries when adults use phrasal intraturn pauses (Bruneau, 1973; Jusczyk, 1997). Just as elderly people benefit from select adult-controlled strategies that include reduced cognitive load, slower linguistic input, and intraturn pauses designed to facilitate syntactic analyses (Dagerman, McDonald, & Harm, 2006; Titon et al., 2006), so do children with auditory processing difficulties (Rowe, Pollard, & Rowe, 2005). Phrasal intraturn pauses improve the attention skills of children with auditory processing atypicalities (Rowe et al., 2005). The use of inserting prolonged pauses between sentences may positively influence language learning for children with atypical capacities for holding, sequencing, and recalling auditory information accurately. A phrasal intraturn pause can render perceptual salience to a particular linguistic unit; therefore, it may be used when acoustically highlighting a particular phoneme for children with hearing loss, e.g., sound-object association activities (Rhoades, 2007).

Benefits of Self-Controlled Pauses Evidentiary findings indicate that there are considerable advantages to using deliberate silences with children with hearing loss who are in the process of learning a spoken language. Practitioners may choose to incorporate these 62

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strategies into their practice. Ten benefits to using interactive silences are discussed here. Facilitates Sustained Auditory Attention By its very nature, self-controlled pauses seemingly facilitate and then maintain children’s attention, yet there is limited evidence for this assumption (Rowe et al., 2005). Given that attention is a core cognitive skill underpinning all executive capacities, this is a critical consideration. Time is ‘bought’ for children to hear or attend to what was said (Rowe, 1996; Tobin, 1983, 1986). When children are routinely expected to actively participate in activities with adults, they tend to become active listeners. For example, experienced practitioners using the Ling Six-Sound Test (Ling, 2003) as part of their therapy sessions intuitively understand the need for absence of sound interspersed with /m/, / a/, /oo/, /ee/, /s/, and /sh/. ‘‘Listening to silences can be just as instructive as listening to voices, maybe more so’’ (Losey, 1997, p. 191). Promotes Listening by Bracketing Meaningful Language Adults can provide impact pauses, usually thought of as stress markers, during extended language input activities without requesting a child follow through with a verbal response. This gives children some uninterrupted time to briefly consider the information in smaller chunks rather than all at once (Stahl, 1994). In turn, this can facilitate attention to specific linguistic units and promote comprehension of a particular construct or pattern. Encourages the Processing of Linguistic Units Young children who are learning a spoken language process that language differently than adults (Swingley, Pinto, & Fernald, 1999). Depending on acoustic-phonetic information and lexical constraints, additional processing time is important for facilitating their comprehension of spoken language (LoCasto, Connine, & Patterson, 2007). Because cognitive processes mediate the effect of adult-controlled pauses on language learning, there is much heterogeneity among children in how they process spoken language and the degree to which interactive silences affect that processing. The processing time afforded children for more complex questions or directions should be greater than the time afforded for a less complex verbal response, relative to each child’s functional level of language (Brown & Wragg, 1993; Tobin, 1987). Nourishes Contemplative and Speculative Thinking Interactive silences are viewed as advanced information processing times (Stahl, 1994; Tobin, 1986; Tobin & Capie, 1983) where children can reflect upon Interactive Silences

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what was said during those intervals (Vassilopoulos & Konstantinidis, 2012). Pause lengths differentially affect how listeners use their cognitive skills (Weiss, Gerfen, & Mitchel, 2010), with more complex questions or responses having a greater effect on how they use their executive capacities (Maroni et al., 2008; Taylor, 1969). Collaboration among children in the classroom is encouraged (Maroni, 2011), particularly because more children tend to verbally participate (Tobin, 1986). In general, more significant educational benefits accrue from silences extending beyond 3 seconds (Altiere & Duell, 1991; Maroni, 2011; Riley, 1986). Informs Listener of Expected Response Both the expectant pause and wait-time, via sustained eye gaze and inflectional voice difference at end of utterances, inform listeners that a response is expected. This expectation, however mild, means these deliberate pauses also serve a prompting function. Provides Time to Formulate a Linguistic Response When children respond to adults, the effort they expend is more cognitively involved than just listening and processing the information (Met, 1994; Nunan, 1987, 1991). Deliberate silences afford children an opportunity to consider how to formulate personal verbal responses (Arco & McClusky, 1981; Halle, Marshall, & Spradlin, 1979). However, Stahl (1994) warns that imprecise adult questions tend to increase a child’s confusion and to heighten frustration, thus leading to no response at all. Wait-times seem to warrant longer periods of deliberate silence. Adults should extend deliberate pauses for children from whom lengthier responses are expected, appropriately modifying them to each child and situation. Fosters Improved Linguistic Responses Frequency, length, and complexity of children’s responses are improved when silence intervals are sufficient in length (Allen & Tanner, 2002; Deelman & Connine, 2001; Pitt & Samuel, 1995; Zwitserlood & Schriefers, 1995), and fewer of their responses are likely to be ‘I don’t know’ (Rowe, 1996). Additionally, the amount of time that adults talk is decreased (Riley, 1986; Skinner, Fletcher, & Henington, 1996). Demonstrates Respect and Value for Each Child’s Opinion Wait-time, think-time, and expectant pauses encourage children to initiate verbal interaction more frequently, possibly because children perceive the adults’ interest in what they have to say (Hayes, 1998). Adults who wait for 64

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children to respond rather than being too quick to repeat the question, execute the direction, or assume a child did not understand, demonstrate respect and value for each child’s opinion (Black, Harrison, Lee, Marshall, & William, 2003). In turn, this facilitates the child’s self-confidence, thus reducing the need for adults to provide positive rewards (Rowe, 1996). When adult rewards decrease, children tend to focus more on the task rather than on what they think adults seek; the source of children’s satisfaction is then altered (Rowe, 1996). Improves Adult Questioning Strategies With consistent use of extended wait-times, the frequency, length, variability, flexibility, and complexity of later adult questions tend to increase in quantity (Rowe, 1996; Tobin, 1986). Moreover, adult reactions to children’s answers tend to be more varied and flexible (Rowe, 1996). Elevates Adult Expectation Levels When children respond appropriately to interactive silences, adult expectations about what the children can do are often modified and, as reviewed elsewhere by Rhoades’ (2010) explanation of expectation levels and the selffulfilling prophecy, this can have a significant influence on learning opportunities afforded the child (Rowe, 1996).

Interactive Silences and Auditory-Based Practice The generic advice of ‘talk, talk, talk’ that is sometimes given to parents of children with hearing loss is not enough. Both quantity and quality of parental and practitioner input matter (Rowe, 2012). The use of adult self-controlled pauses reflects good pedagogy that enhances cognitive development and interactive communication for both language and academic learning children (Carlsen, 1991; Leach & LaRocque, 2011; Vassilopoulos & Konstantinidis, 2012). At the least, wait-time is a type of interactive silence that has been incorporated into some practitioner observation tools for those who work with children who have typical hearing and those with hearing loss (Baysen & Baysen, 2010; Brown, 2008). The Need for Effective Implementation Silence makes for great discomfort in some adults, including inexperienced practitioners (Ollin, 2008). For many reasons, it can be challenging for practitioners and parents to employ deliberate silences as a conscious strategy within their respective settings. Entrenched patterns of interaction, considered ritualized teaching behaviors, may be modified with some difficulty (Maingay, 1988; Thornbury, 1996). Adults may feel uncomfortable when stripped of their Interactive Silences

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dependence on non-interactive talking. Studies show that it can be relatively easy to effect changes in their use of interactive silences (Nind, 1996; Vassilopoulos & Konstantinidis, 2012), but maintaining extended pauses in the months following training may be problematic for some (Tobin, 1987). Nevertheless, it is important to sensitize adults to their own use of interactive silences simply due to the evidence supporting its importance to the language learning process (Beckwith & Rodning, 1996; Murray et al., 1990). Short video self-analyses can be very important to sensitization and practitioner training processes (Baysen & Baysen, 2010; Phillips, 1994); therefore, it is suggested that this type of critical reflection be integral to the mentoring process. Such selfanalyses, also referred to as discourse analysis, can force individuals to confront their own teaching habits and style (Nunan, 1987). It is imperative that this raised awareness of interactive silences, along with appropriate questions and answers as well as affective and cognitive engagement of all involved persons, be translated into clinical and classroom practice. Awareness-raising and reflection can and do facilitate positive change (Kumaravadivelu, 1994; Swift & Gooding, 1983). Carey-Sargeant and Brown (2003) state ‘‘...the overt teaching of how to use pause length as a communication strategy may be a practical and useful tool, particularly within early intervention programs, for developing the language and communication skills of children with a hearing impairment’’ (p. 56). Skilled practitioners can learn how to routinely implement self-controlled pauses that are appropriate to an individual child’s needs and situations. Implementation of deliberate silences provides clear advantages for all children, including improvements in behavioral functioning, language comprehension, and academic learning. Assuming the art of timing has been mastered, prolonged moments of silence can afford auditory-based practitioners and parents of children with hearing loss with some highly effective operational strategies. To paraphrase the poet Oliver Herford, experienced practitioners should be known by the silence they keep. The Call for Evidence There are cross-linguistic findings pertaining to timing issues of interactive silences for people with typical hearing (as reviewed by Heldner & Edlund, 2010). There is also evidence that deliberate pauses are integral to childdirected speech, which facilitates the language learning process for children developing typically and atypically across cultures and languages (Bergeson, Miller, & McCune, 2006; Kempe, Schaeffler, & Thoresen, 2010; Sheng, McGregor, & Xu, 2003). In a study of adolescents with typical hearing, waiting longer than 5–6 seconds did not yield significant response differences (Duell, 1994). This sort of finding raises an important question: Is there a point of diminishing returns with wait-times that are extended beyond a certain number of seconds? Does the optimal range of wait-time considerably vary 66

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from younger children to adolescents? To what extent is length of wait-time affected by the linguistic complexity of queries directed at language learning children with hearing loss? While the use of wait-time has been researched with some children with cognitive delays (Halle et al., 1979; Heeman et al., 2010; Tincani & Crozier, 2007), this operational variable has yet to be studied for outcome effectiveness among practitioners serving children and adolescents with hearing loss. There is no evidence as of yet that wait-time should be of a particular duration when used with children whose auditory access to spoken language is compromised. Additionally, there is limited evidence that the length of phrasal intraturn pauses during verbal interactions between parents and children with hearing loss should be slightly longer and varied as a function of the child’s language level (Carey-Sargeant & Brown, 2003). Do all young children with hearing loss benefit from longer phrasal intraturn pauses? Would more perceptual and cognitive processing time for children with hearing loss facilitate the language learning process? If so, what is the optimal pause duration—500 milliseconds? 1–3 seconds? Does the child’s aided/implanted threshold serve as a mediating variable, and, if so, to what extent? Unanswered questions have to do with length and frequency of these different types of interactive silences as a function of chronological age, functional language level, degree of auditory access to soft conversational sound, cultural background, and executive capacities as evidenced by individual children. It has been suggested that further studies ‘‘could improve sensitivity to the interactional relevance of pause and maximize professional education and therapy techniques’’ (Carey-Sargeant & Brown, 2003, p. 55). Just as spoken language matters, judicious use of silence also matters.

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The Volta Review, Volume 113(1), Spring 2013, 75–76

Book Review Building Comprehension in Adolescents Building Comprehension in Adolescents By Linda H. Mason, Robert Reid, and Jessica L. Hagaman Paul H. Brookes Publishing Soft cover, 2012, $34.95, 272 pages Due to improved brain imaging and an increase in data, the neurobiological perspective on learning has evolved over the past three decades to embrace the broad construct of executive functioning, or cognitive control. This refers to those deliberate top–down processes involved in the conscious, goal-directed problem solving processes, grouped into two constellations of skills known as meta-cognition and self-regulation. Starting in infancy and developing across childhood, strong executive capacities facilitate the learning process, including the acquisition of good reading and writing skills. Historically, many adolescents with hearing loss are identified as functionally illiterate. Likewise, data of the past two decades show that many children and adolescents with hearing loss demonstrate weak executive capacities. In short, children and adolescents with hearing loss are often struggling learners. Mason, Reid, and Hagaman have co-authored a very practical book that targets adolescents who are struggling learners. Their book, Building Comprehension in Adolescents, aims to provide practitioners with an evidencebased instructional model that will strengthen the executive capacities of adolescents as well as facilitate their reading comprehension and written expression. This guidebook of systematically implemented strategies can help students improve their vocabulary along with varied reading and writing skills. Executive capacities, including attention, goal setting, inhibitory control, and organization, can be considerably improved. The chapters within this book are divided into four sections. The first section presents the author’s Self-Regulated Strategy Development Model for practitioners to implement. Readers will come to understand the framework for effective student learning; that is, an evidence-based, systematic instructional approach to facilitate reading, writing, and critical goal-directed problem solving learning skills (otherwise known as executive functioning). The second section focuses on reading to learn, the third section on writing to learn, and the fourth section on homework across academic content. Each of these well-organized sections include detailed lesson plans that provide overviews, objectives, suggested teacher scripts, explicit step-by-step instrucBuilding Comprehension in Adolescents

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tions, detailed vignettes, and worksheets that can easily be copied for individual or group use. A variety of self-monitoring checklists, goal charts, self-instruction sheets, mnemonic devices, and visual clarifiers are made available to students. Practitioners are directed to the effective use of group collaboration and peer practice as well as the fading of instructional supports. Furthermore, the authors present scaffolding practices on three levels: content, task, and material; these are included across the chapters in sections II through IV. The authors provide strategies that enable students to effect both internal and external control. They show practitioners how to implement personcentered supports by verbalizing the learning process and asking questions that facilitate self-reflection, encouraging self-directed talk. The authors also show practitioners how to implement task modifications with the use of lexical support, behaviorally stated problems and goals, task analysis instruction, visual imagery, and graphic organizers. Research findings supportive of these strategies are also cited at the end of appropriate chapters. Although the authors explicitly targeted this book for practitioners serving students in middle/junior and secondary/high school, practitioners working with younger children can also benefit from this model, which embraces effective instructional strategies regardless of content area. Itinerant and resource practitioners as well as classroom teachers can use these thoughtfully presented plans and strategies for the individual adolescents being served. This sort of systematic instruction will clearly benefit struggling learners, including those with hearing loss. Those practitioners who do not fully understand executive functioning and how to facilitate those executive capacities would do well to use this book as a guide in serving all students with hearing loss. Practitioners implementing this model can enable students with hearing loss to become independent, self-regulated learners. Regardless of educational setting and how practitioners use it, this book should serve as an excellent resource. Ellen A. Rhoades, Ed.S., LSLS Cert. AVT, is an auditory-verbal consultant and mentor whose services can be accessed through www.AuditoryVerbalTraining.com. Correspondence concerning this article may be directed to Dr. Rhoades at [email protected].

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Information for Contributors to The Volta Review The Volta Review is a professional, peer-review journal inviting manuscripts devoted to reporting scholarly findings that explore the development of listening and spoken language by individuals with hearing loss. Its readership includes teachers of students who have hearing loss; professionals in the fields of education, speech, audiology, language, otology, medicine, technology and psychology; parents of children who have hearing loss; and adults who have hearing loss. Established in 1899, The Volta Review is the official journal of the Alexander Graham Bell Association for the Deaf and Hard of Hearing, an international nonprofit organization, based in Washington, D.C., particularly interested in the communication abilities of people with hearing loss. The journal is published three times annually, including two regular issues and a special, single-topic monograph issue each year. The Volta Review currently seeks manuscripts of empirically based studies focusing on practical or conceptual issues with the result of advancing knowledge relevant to the communication needs and abilities of people with hearing loss. Group and single-subject designs are acceptable. Manuscript Style and Submission Requirements In general, manuscripts should conform to the conventions specified in the Publication Manual of the American Psychological Association (APA) 6th ed. (2010) with the exceptions and considerations given below. Submission. A cover letter and one copy of a blinded manuscript and accompanying figures should be submitted electronically to the Managing Editor at [email protected]. Preparation. Please double-space all materials. Number pages consecutively with the title page as page 1. The title page should include all authors’ names and affiliations, regular mail and email addresses, telephone and fax numbers for the corresponding author, and a running head. No authoridentifying information should appear anywhere other than the title page of the manuscript. Include an abstract of 100–150 words as page 2. Assemble the rest of the manuscript in the following order, starting each part on a new page: First and subsequent pages of the text; acknowledgements (include citations of grant or contract support here); references; tables; figure captions; and figures. Refer to Merriam-Webster’s Collegiate Dictionary, 10th Edition for preferred spellings. Length. Limitations on length of manuscripts are based on the type of submission. The following page recommendations apply. Research papers are subject to a page limitation of 35 pages including tables and figures. Manuscripts exceeding the page limitations are occasionally accepted for publication on a space-available basis. 77

References. All references should be closely checked in the text and reference list to determine that dates and spellings are correct. References must follow APA style and format. Tables. Include each table on a separate page. Number tables consecutively using Arabic numerals. Each table should be referred to in the text by its number. Indicate where the tables should appear in consecutive numerical order in the text, but do not insert tables into the text. Figures. Each figure must be referred to in the main text in consecutive numerical order using Arabic numbers. Non-graphic information should not appear as figure artwork, but in the figure legend. Hand lettering is unacceptable and standard abbreviations should be used. (e.g., dB not db or dB) Lettering or symbols appearing on the figure artwork should be as large as possible so they will still be legible when reduced. Figure legends (captions) must be typed double-spaced on a separate sheet of paper at the end of the manuscript. Figure legends should not appear on the artwork. If a table or figure has been previously published, it is the author’s responsibility to obtain written permission to adapt or reprint the figure or table from the copyright holder, even if it is the author’s own previously to reproduce it must be obtained from the publisher. This applies to any figure, table or illustration or to direct quotes from another work. You will be required to submit proof of permission to the Managing Editor. Please alert the managing editor to potential copyright permission issues when the manuscript is submitted. (Photocopies of the agreement are required as proof.) High resolution figures files are necessary for final production if your article is accepted for publication. Files can be submitted via email as .tiff, .jpg or .eps files with a resolution of 300 dpi at size. The Volta Review does not accept art that is in color or downloaded from the Internet. Photocopy reproductions are not acceptable as final printer’s copy; however, photo copies should be submitted for the reviewer’s purpose. Photographs. Photographs of special equipment or materials are often desirable; however, photos of standard classroom or clinical apparatus are not instructive and should not be included with the manuscript. Footnotes. As a general policy, using footnotes within the text is discouraged; however, in certain circumstances (such as for limited clarification of terminology) footnotes can be unavoidable. In such cases, use asterisks (*) as footnotes. Terminology. To describe individuals’ hearing status, please use the phrase ‘‘deaf or hard of hearing’’ or ‘‘with hearing loss’’ instead of ‘‘hearing impaired’’. In addition, please use ‘‘people first’’ language (i.e., ‘‘students who are deaf or hard of hearing’’ or ‘‘students with hearing loss’’ instead of ‘‘hearing-impaired students’’). If authors choose not to follow this style, provide a rationale for using the chosen terminology. The rationale may be provided in the form of an author’s note or may be integrated into the text of 78

the manuscript. The journal reserves the right to change terminology for readability purposes with the consent of the author. Review. All manuscripts are subject to blind review by three or more members of the Review Panel. No author-identifying information should appear anywhere other than on the title page of the manuscript. The review process takes three to four months to complete. Reviewers comments are shared with author(s). Editing. The Editor, Associate Editors and the Managing Editor of the journal will edit your manuscript to verify content and to enhance readability, as well as for consistency of style and correctness of grammar, spelling and punctuation. Authors will be given an opportunity to review their edited manuscripts before they are set in type. Also, if the publication schedule permits, authors will be sent page proofs of their typeset articles for final review. Authors should mark only typesetter’s errors and/or answer any questions directed to them by the Managing Editor. No copy changes should be made at this time. Use of Word Processing. Authors must submit electronic files of their manuscript and accompanyng figures and table files to the Managing Editor once the article is approved for publication. Please use Microsoft Word only and supply a hard copy of the figures and tables. You must submit your manuscript via email to [email protected]. Transfer of Copyright. The revised copyright law, which went into effect in January 1978, provides that from the time a manuscript is written, statutory copyright is vested with the author(s). This copyright can be transferred only by written agreement. Without copyright ownership, the Alexander Graham Bell Association for the Deaf and Hard of Hearing cannot issue or disseminate reprints, authorize copying by individuals and libraries, or authorize indexing and abstracting services to use material from the journal. Therefore, all authors whose articles have been accepted for publication in The Volta Review are requested to transfer copyright of their articles to the association before the articles are published. Categorizing for Index. Authors are required to designate, in the cover letter accompanying the manuscript, the primary audience to whom the information is of most use and interest. When a manuscript is accepted for publication, its corresponding author will be asked to fill out a more detailed categorization form to be used in preparing an index published in the winter issue of each year. Reprints. At the time of publication of the journal, each contributing author is sent three complimentary copies of the issue. Additional reprints of published articles are available at cost to the author. These must be ordered through the Periodicals Department, The Volta Review, 3417 Volta Place, NW, Washington, DC 20007. Order forms are sent to authors with initial 79

complimentary copies. Authors are not permitted to sell reprints themselves once copyright has been transferred. Author’s Responsibility Author guarantees, when signing a contract with a publisher, that the work is original, that the author owns it, that no part of it has been previously published, and that no other agreement to publish it or part of it is outstanding. If a chapter or other significant part by the same author has been published elsewhere, written permission to reprint it must be secured from the copyright holder of the original publication and sent to the publisher. It is the author’s responsibility to request any permission required for the use of material owned by others. When the author has received all permissions, the author should send them, or copies of them, to the publisher. The author must provide accurate information regarding the source of any such material in their work. Permission for the use of such entities as poems, musical works, or illustrations, even when no fee is charged, is normally granted only for the first edition of a book. New editions, paperback reprints, serialization in a periodical, and so forth, will require renewed permissions from original copyright holder. The author is responsible for any fees charged by grantors of permission to reproduce, unless other arrangements are made, in writing, with the publisher. Fees paid for reproducing material, especially illustrations procured from a picture agency, normally cover one-time use only. Whether or not the author needs permission to use any material not their own, an author should give the exact source of such material: in a footnote or internal reference in the text, in a source note to a table, in a credit line with an illustration. Where permission has been granted, the author should follow any special wording stipulated. Material Requiring Permission Copyrighted Material: The author of an original book must have written permission to use any copyrighted material that is complete in itself: short story, essay, chapter from a book, etc. The author should also seek permission to use more than one line of a short poem still in copyright or any words or music of a popular song. No permission is required for quoting from works in the public domain. ‘‘Fair Use’’: The ‘‘Fair Use Clause’’ generally allows copying without permission from, or payment to, the copyright owner where the use is reasonable and not harmful to the rights of the copyright owner. Without prescribing precise rules to cover all situations, the clause refers to ‘‘purposes such as criticism, comment, news reporting, teaching (including multiple copies for classroom use), scholarship, or research,’’ and sets out four factors to be considered in determining whether or not a particular use is fair: 80

   

The purpose and character of the use, including whether or not such use is of commercial nature or is for nonprofit, educational purposes; The amount and substantiality of the portion used in relation to the copyrighted work as a whole; The nature of the copyrighted work; The effect of the use upon the value or potential market of the copyrighted work.

The Alexander Graham Bell Association for the Deaf and Hard of Hearing encourages the author to obtain written permission for any quotation of 150 or more copyrighted words. The author may not copy any part of a copyrighted work unless he or she used quotation marks, indicates the source of the quotation, and if 150 of more words in length, obtains written permission from the copyright holder. Authors are required to designate, in the cover letter accompanying the manuscript, the primary audience to whom the information is of most use and interest. When a manuscript is accepted for publication, its corresponding author will be asked to fill out a more detailed categorization form to be used in preparing an index published in the winter issue of each year.

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