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The Volta Review
Volume 108, Number 1
ISSN 0042-8639
The Volta Review
Alexander Graham Bell Association
for the Deaf and Hard of Hearing
The
Volta
Review
The Volta
Review
ISSN 0042-8639
Spring 2008
Organized in 1890 to encourage the teaching of speech, speechreading and the use of residual hearing to
people who are deaf or hard of hearing, the Alexander Graham Bell Association for the Deaf and Hard of
Hearing (AG Bell) welcomes to its membership all who are interested in improving educational, professional and vocational opportunities for people who are deaf or hard of hearing. Affiliated with AG Bell are the
Parent Section, the Deaf and Hard of Hearing Section and the International Professional Section.
Editor’s Preface
3
Patricia M. Chute, Ed.D.
Research
5
The Emotional Well-Being of Older Siblings of Children Who
Are Deaf or Hard of Hearing and Older Siblings of Children
with Typical Hearing
Renuka Sundaram Raghuraman, Ph.D., A.T.R.-B.C.
37
Reading Comprehension of an Inferential Text by Deaf
Students With Cochlear Implants Using Cued Speech
Santiago Torres, Ph.D, José-Miguel Rodríguez, Ph.D., Javier García-Orza, Ph.D.,
and Marina Calleja, Ph.D.
59
The Conditioned Assessment of Speech Production (CASP): A
Tool for Evaluating Auditory-Guided Speech Development in
Young Children with Hearing Loss
David J. Ertmer, Ph.D., and Carol Stoel-Gammon, Ph.D.
Regular Features
81
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 Web sites 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 resale without the express written
permission of the publisher. For more information, contact AG Bell at 3417 Volta Place,
NW, Washington, DC 20007, e-mail [email protected], or call 202/337-5220 (voice) or
202/337-5221 (TTY).
Editor’s Preface
Patricia M. Chute, Ed.D.
As I write my final preface for The Volta Review, I am reminded that my role
as editor was accomplished only with the support and talents of an extraordinary editorial board. The time and energy of Alice Eriks-Brophy, Carolyn J.
Brown, Laurie S. Eisenberg, Howard Francis, Kevin Franck, Karen Iler Kirk,
Susan Lenihan, Mary Ellen Nevins, and Michael D. Seidman was paramount
in producing a quality journal at each publication. I will be stepping down to
become the Interim Dean of the School of Health and Natural Sciences at
Mercy College in Dobbs Ferry, New York, thereby limiting the amount of time
that I would be able to provide the attention that being editor demands. For
my final issue, however, the research that is contained in this volume proves,
once again, that there are still many concerns that require attention when
determining the best approach in addressing the needs of the deaf and hard
of hearing population. Speech development, reading comprehension, and
emotional well-being of siblings of children with hearing loss are the topics
presented in this release of The Volta Review.
Raghuraman investigates older siblings of typically developing children
and those with hearing loss. Although no significant differences were found
overall, there were some gender disparities that were related both to severity
of hearing loss and positive temperament. As cochlear implants become more
prominent within the deaf population, more studies dealing with social emotional issues such as those outlined in this study need to be supported. Additionally, as the number of culturally and linguistically diverse families
increases, the contributions that ethnicity makes with regard to family dynamic and development of self also requires exploration.
A second contribution from Málaga, Spain, by Torres, Rodrı́guez, Garcı́aOrza, and Calleja investigate cued speech, cochlear implants, and an inferential reading task in four children with hearing loss, comparing them to a
larger group of chronologically aged hearing peers and reading age-matched
hearing peers. Although the overall sample size was small, the combination
of the cochlear implant and cued speech (along with the development of good
spoken language skills) permitted the children with implants to perform
similarly in a task of inferential reading with reading age-matched hearing
peers. As more children with cochlear implants progress through the school
systems, the improved development of their reading skills underscores the
impact implant technology has on educational outcomes.
Finally, Ertmer and Stoel-Gammon describe the development of a tool
called the Conditioned Assessment of Speech Production (CASP) in an attempt to quantify early gains in vocal output as a result of access to audition.
With the majority of children who are deaf or hard of hearing receiving
cochlear implants at young ages, the need for such a tool is critical as we
attempt to monitor outcomes of these children as well as those with hearing
aids. Field testing of this tool indicated that it could be used with children as
young as 12 months of age, thereby providing important information to clinicians, educators, and parents of children with hearing loss. Assessments
like CASP are becoming more necessary as early amplification and implantation occurs. Clinicians will find this new tool invaluable, especially when
attempting to quantify early gains in vocal output as a result of auditory
access.
In closing, I would like to say what a pleasure it has been to work with AG
Bell on The Volta Review the past six years as editor. AG Bell’s commitment to
the professionals and parents of deaf and hard of hearing children and deaf
and hard of hearing adults continues to make it the primary organization for
individuals with hearing loss. It has been an honor to have served this association all these years and I am certain that my successor will have the same
support and confidence that I enjoyed during my tenure as editor.
Pat Chute, Ed.D.
Editor
The Volta Review
4
The Volta Review, Volume 108(1), 5–35
The Emotional Well-Being of
Older Siblings of Children
Who Are Deaf or Hard of
Hearing and Older Siblings of
Children with Typical Hearing
Renuka Sundaram Raghuraman, Ph.D., A.T.R.-B.C.
This study explores the emotional well-being of older siblings of children who are
deaf or hard of hearing and older siblings of children with typical hearing (control
group). We interviewed 70 families and had both the parent and the older sibling
complete questionnaires on sibling perceptions and relationships. Findings revealed
no significant differences between older siblings in the two groups on psychological
variables, parental attention, and household responsibilities. However, gender differences did emerge. Parent and child ratings on questionnaires were similar, with the
exception of interpersonal concerns. Regarding group relations, the older siblings of
children who are deaf or hard of hearing showed fewer behavioral problems as the
severity of the hearing loss increased. Also, older siblings who had a more positive
temperament exhibited fewer behavior problems. The lack of significant differences
between the two groups suggests that older siblings of children who are deaf and hard
of hearing experience a spectrum of positive and negative feelings similar to those of
older siblings of children with typical hearing.
Introduction
More study of the entire family system is needed to better understand how
families of children with disabilities interact. Previous research has focused
on the impact of the disability on the parent dyad or the parent-child dyad,
Renuka Sundaram Raghuraman, Ph.D., A.T.R.-B.C., is a board-certified art therapist with
experience in pediatric, forensic, and psychiatric settings. She has also worked extensively with
families of children with disabilities, particularly siblings, and is currently teaching yoga to
children with special needs. Correspondence concerning this article should be addressed to
Renuka Sundaram Raghuraman at [email protected].
The Emotional Well-Being of Older Siblings
5
with little regard for the rest of the family, especially siblings (Dyson, Edgar,
& Crnic, 1989; Kramer & Bank, 2005; McHale, Sloan, & Simeonsson, 1986).
One study of families of children who were deaf or hard of hearing looked at
parental perspectives but not sibling perspectives (Israelite, 1986). A small but
burgeoning body of literature recognizes the strong influence that siblings
have on the overall function of the family (Dunn, 2005; Kramer & Bank, 2005).
Existing research suggests that siblings of children with disabilities experience a similar continuum of positive and negative emotions as siblings of
children with no disabilities (Stoneman & Berman, 1993). For example, some
siblings of children with disabilities may be more tolerant, helpful, caring,
and responsible, and may serve as role models. On the other hand, siblings
may have fears about “catching the illness,” may overcompensate, or may feel
guilt (“why him, not me?”) or embarrassment about having a sibling with a
disability (Crnic & Leconte, 1986). Siblings’ level of adaptation depends on
their parents’ attitude and response to the disability, the extent of parental
availability, and their own level of maturity and understanding (Cicirelli,
1995; Dyson et al., 1989; Kramer & Bank, 2005; Stoneman & Berman, 1993).
Sibling relationships in young childhood are marked by considerable variability in interactive behaviors and relationships typically have both positive
and negative aspects (Cicirelli, 1995; Dunn, 2005). Greater attention should be
paid to individual differences among siblings of children with disabilities
(Dyson et al., 1989).
There are very few published studies about siblings of children who are
deaf or hard of hearing, and the field would be greatly enriched by more
knowledge of siblings’ contributions to the family dynamic (Bat-Chava &
Martin, 2002). This study explores the emotional well-being of older siblings
of children who are deaf or hard of hearing. This study has two primary
goals. First, it seeks to identify any group or gender differences between older
siblings of children who are deaf or hard of hearing and older siblings of
children with no disabilities on the psychological variables of warmth/
closeness, conflict, and depression; perceived parental attention; and sibling
activities and responsibilities. Second, this study seeks to determine which
child, parent, or family variables (within group relations) relate to individual
differences among older siblings of children who are deaf or hard of hearing.
In examining these two issues, this study attempts to understand the concerns
of older siblings by reviewing their perspectives on having a brother/sister
with a hearing loss.
Literature Review
Siblings of Children with No Disabilities
Minuchin (1974) describes the family as a powerful system divided into
subsystems. He posits that family relationships are interdependent and mutually interactive, and that change in one part of the system dynamically
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Raghuraman
affects all the other subsystems. The impact of any upheaval is crucial. Siblings’ personalities and experiences shape the way they perceive and respond
to their environment, and their immediate family has the greatest influence
during their formative years (Cicirelli, 1995; Kramer & Bank, 2005; Stoneman
& Berman, 1993). Understanding sibling interaction in families of children
with no disabilities can create a foundation for examining interactions of
older siblings of children who are deaf or hard of hearing (Stoneman &
Berman, 1993). Family constellation variables—such as gender, temperament,
culture, ethnicity, income, and birth order—are all discussed (Stoneman &
Brody, 1993).
Gender
Older brothers and sisters can serve as positive role models, playmates, and
companions for their younger siblings (Cicirelli, 1995, McHale, Whiteman,
Kim, & Crouter, 2007). Younger siblings frequently imitate and model the
behaviors and actions of their older siblings (Cicirelli, 1995). Younger siblings
tend to look to older sisters more than older brothers for security and help;
and older sisters tend to show more nurturing, warmth, intimacy, cooperation, and closeness toward their younger siblings than older brothers (Buhrmester & Furman, 1990; McHale et al., 2007). Girls rate sisters higher than
brothers, but there is no significant trend for boys to rate brothers higher than
sisters (Buhrmester & Furman, 1990). Older boys are more friendly and positive toward younger brothers than they are toward younger sisters (Dunn &
Kendrick, 1982). Although feelings of warmth and closeness are higher
among siblings of the same gender, this finding is significant only among
sibling dyads less than four years a part (Furman & Buhrmester, 1985; Lamb
& Sutton-Smith, 1982; Powell & Ogle, 1985).
Temperament
Temperament is expressed through behaviors, feelings, and attitudes (Keogh, 1982; Thomas, Chess, & Birch, 1968). Children with an easy temperament
show a predominantly positive mood, low or mild intensity in reactions, and
high adaptability to new situations or unfamiliar people (Thomas et al., 1968;
Thomas & Chess, 1986). Children who are positive in mood show more
interest, cooperation, and affection toward younger siblings (Dunn & Kendrick, 1982). High adaptability and low intensity result in more positive interactions between siblings and more participation in joint activities at home
(Stevenson-Hinde & Hinde, 1986). Parents’ differential treatment of siblings
can affect siblings’ perceptions of their parents’ fairness and the nature of the
sibling relationship (McHale, Updegraff, Jackson-Newsom, Tucker, &
Crouter, 2000).
Children with a difficult temperament tend to negatively respond to or
7
withdraw from new people and situations, adapt slowly to changes, and
frequently express negative moods and intense reactions (Thomas et al., 1968;
Thomas & Chess, 1986). In one child temperament study, high activity, high
emotional intensity, and low persistence led to more aggressive behaviors
and conflict between sisters (Brody, Stoneman, & Burke, 1987). Children who
are negative in mood and extreme in emotional intensity are more likely to
respond to the birth of a new sibling by becoming clingy (Brody et al., 1987).
Siblings who show negative behaviors can influence parental attitudes and
contribute to further sibling maladjustment (Feinberg, Reiss, Neiderhiser, &
Hetherington, 2005).
Temperament can influence the degree of companionship, rapport, support, role-modeling, rivalry, favoritism, and competition among siblings
(Brody & Stoneman, 1993; Brody et al., 1987; Cicerelli, 1995).
Other factors
Culture, ethnicity, and socioeconomic status. Culture and ethnicity are important
constellation variables in understanding family dynamics. In one study, African Americans relied on extended family and family members to contribute
to the overall functioning and well-being of the family (McHale et al., 2007).
Parental practices, traditions, and morals related to ethnic and cultural backgrounds can uniquely shape family dynamics in minority families (McHale et
al., 2007). However, some studies show that dynamics in the families of
African Americans and other minority groups are similar in many ways to
those of majority-culture families such as European Americans (Boykin &
Toms, 1985).
Families with limited financial resources might not be able to afford child
care, so parents might rely on older children to share the responsibilities
(Lobato, Faust, & Spirito, 1988). In one study on African American and Latino
families from financially stressed backgrounds, family members rallied together and helped each other out, and sibling relationships were positive
(McHale et al., 2007). Families from upper and middle class environments
may have greater access to resources, but their expectations of their children
may also be higher (Cicerelli, 1995; Lobato et al., 1988).
Birth order. After the birth of a younger sibling, first-born children may feel
that their parents no longer love them as much, are partial toward the
younger sibling, or pay more attention to the younger sibling (Dunn, 1985;
Dunn & Kendrick, 1982). Parents may delegate new responsibilities or encourage increased independence in older siblings, so they can have more time
to meet the needs of the new child (Boer & Dunn, 1992; Gibbs, 1993; Lobato,
1990). On the other hand, older siblings may be excited about the new child
as a potential playmate, friend, and confidante (Cicirelli, 1995; Lamb & Sutton-Smith, 1982). They may be eager to help care for the younger child,
8
Raghuraman
demonstrate affection and friendliness, make attempts to communicate with
the baby, and model prosocial behaviors (Buhrmester & Furman, 1990).
Siblings of Children with Disabilities
Families who have a child with a disability may experience disruption of
their daily life (Lobato, Kao, & Plante, 2005). Siblings with a brother or sister
who has a disability may need to adjust to the changes and their new roles
(Dyson, 1998; Featherstone, 1980). Past research has focused on the negative
consequences of having a sibling with a disability, while more recent studies
have found that the emotional adjustment of children who have a brother or
sister with a disability falls within the normal range (Crnic & Leconte, 1986;
Dyson et al., 1989; McHale et al., 1986). Many studies still look only at parental input, although research is beginning to include other family members’
perspectives (Nixon & Cummings, 1999).
Positive aspects
Children with a disability can bring out the best in their siblings, including
insight, understanding, and enlightened perspectives on interactions and
bonding (Crnic & Leconte, 1986; Dyson, 1998). Care giving experiences and
supportive networks outside the home may help these older siblings, especially older sisters, develop greater tolerance (Dyson, 1998; Dyson et al., 1989;
Lobato et al., 1988). Some studies indicate that siblings of children with a
disability are well-adjusted and demonstrate maturity and a heightened sense
of responsibility for their age; many choose humanitarian professions
(McHale & Gamble, 1989; McHale et al., 1986). Many positive interactions
involve higher levels of awareness such as empathy and altruism, increased
flexibility and tolerance for differences, and pride in the accomplishments of
the child with a disability (Dyson, 1998; Powell & Ogle, 1985). Siblings can
promote the social development of the child with a disability by helping the
child integrate in a social setting, involving peers, or acting as positive role
models (Atkins, 1987; Crnic & Leconte, 1986).
Some studies have not shown positive effects. One study looked at siblings
of children with autism, siblings of children with mental retardation, and a
control group of siblings of children with no disabilities. The studies found no
group differences on sibling attitudes or maternal ratings of the siblings with
regard to acceptance, hostility, support, and embarrassment (McHale et al.,
1986). In another study, no group differences were found between siblings of
children with disabilities and siblings of children without disabilities with
regard to understanding of developmental disabilities, level of empathy and
acceptance, and level of child care responsibilities (Lobato, Barbour, Hall, &
Miller, 1987). These findings are important because they convey the message
9
that a child’s perceptions about having a brother or sister with a disability
may be no different from perceptions about siblings with no disability.
Negative aspects
Historically, past studies have explored possible risk factors for psychological maladjustment that may accompany the disability (Lobato et al., 2005).
Some children whose brother or sister has a disability may feel guilty that
they are “normal” or somehow responsible for the disability because of a bad
thing they did; or they may worry about “catching” the disability (Lobato,
1990; Mindel & Feldman, 1987; Powell & Ogle, 1985). Siblings are sensitive to
their parents’ emotional state. For example, they may not want to upset their
parents, so they may keep quiet about their feelings (Atkins, 1987; Cicerelli,
1995; Crnic & Leconte, 1986). In addition, parents might expect children to
somehow compensate for what their brother or sister with a disability cannot
do (Lobato, 1983). Older girls who are the only other sibling in the family
believe that their parents have higher caretaking expectations of them than
older girls in families where no children have a disability (Atkins, 1987;
Luterman, 1996).
Older siblings may also worry about the social stigma of being with a
brother or sister who has a disability (Boyce & Barnett, 1993; McHale et al.,
2007; Nixon & Cummings, 1999). They may have to cope with reactions of
peers toward their brother or sister with a disability during social interactions
in mainstreamed classrooms, on the school playground, and in the community (McHale et al., 1986). They may not want their friends to see their brother
or sister with a disability out of fear that they or their sibling will be treated
badly, or even just differently (Crnic & Leconte, 1986: Harvey & Greenway,
1984; McHale et al., 2007; McKeever, 1983). On the other hand, they may feel
protective and supportive of their brother or sister with a disability, which
may trigger conflict with unsupportive peers (Nixon & Cummings, 1999).
Children’s reactions to their brother’s or sister’s disability depend to some
extent on their attitudes and their level of communication with their parents
(Bat-Chava & Martin, 2002; Dunn, 2005). Parents who encourage open and
honest communication promote a more healthy understanding in their children than parents who communicate less openly (Lobato, 1990; Lobato et al.,
2005). Supportive resources outside the home—such as programs designed to
address sibling needs—can play a vital role in siblings’ level of adaptation
(Dyson, 1998).
Other factors
Birth order. First-born siblings may feel singled out if their parents are not able
to spend as much time with them after the birth of the younger child (Atkins,
1987; Lobato, 1990; Powell & Ogle, 1985). Parents may also involve the older
10
Raghuraman
sibling in the care of the younger child who has a disability (Atkins, 1982;
Breslau, Weitzman, & Messenger, 1981). Older siblings may have greater
mother-surrogate responsibilities, such as babysitting, caring for, or accompanying the child who has a disability (Crnic & Leconte, 1986). Siblings may
come to feel that their interactions with their younger brother or sister are
work, not play (Cicirelli, 1995). Bat-Chava and Martin (2002) indicate that
older siblings of children who are deaf or hard of hearing had more “mixed”
or “negative” relationships with them, whereas younger siblings had more
“positive” or “very positive” relationships with them.
Culture, ethnicity, and socioeconomic status. Few studies exist on how culture and
ethnicity impact a child’s level of adaptation to a sibling with a disability
(Lobato et al., 2005). In one study, Latino families from socioeconomically
stressed backgrounds depended on cultural values and a strong sense of
family to help them adjust to having a child with a disability (Lobato et al.,
2005). However, this study also found that families from impoverished backgrounds had less access to resources and, therefore, did not receive vital
education, information, and support.
Older siblings from middle class backgrounds have more trouble adjusting
emotionally because of social stigma, and oldest siblings from low socioeconomic backgrounds are more adversely affected as a result of increased caretaking responsibilities (Gath, 1974; Grossman, 1972). In general, the reactions
of older siblings to a child with a disability seem to be similar to those of older
siblings to their brothers and sisters with no disabilities. Both positive and
negative feelings exist in all sibling relationships, and parental attitudes and
the personality of each child are vital factors shaping the sibling relationship
(Stoneman & Brody, 1993).
Deafness
In families with no history of or exposure to deafness, having a child who
is deaf or hard of hearing may cause a family crisis, in which existing family
structures are uprooted and disequilibrium occurs (Bat-Chava & Martin,
2002; Featherstone, 1980). Parents may worry about how their child with a
hearing loss will function in a hearing world, what their families and friends
will think, and what the impact of the disability will be on the rest of the
family (Meadow-Orlans, 1990). Communication regarding basic needs may
become an issue between the child and the rest of the family and between the
child and others in the community (Bat-Chava & Martin, 2002). Unlike hearing children, who naturally acquire language and speech, a child with a
hearing loss is denied access to verbal communication and must be taught
verbal skills (if parents choose the oral route) (Koester & Meadow-Orlans,
1990).
However, the situation does have positive aspects. The child who is deaf or
11
hard of hearing may capitalize on the use of technology to access audition and
other sensory capabilities. Family members may develop greater resiliency
and enhanced communication skills, becoming more empathic, flexible, and
accommodating. Parents and siblings may become strong advocates or adopt
humanitarian stances (Mindel & Feldman, 1987). And, like any other child,
the child should be considered a child first and a person with a disability
second (Atkins, 1987).
Siblings of Children Who Are Deaf or Hard of Hearing
Literature is scarce on the psychological adjustment of siblings of children
who are deaf or hard of hearing (Israelite, 1986). Existing studies generally
rely on extensive case studies or on parents’ reports, without interviewing
siblings (Israelite, 1986). The few studies of siblings of children who are deaf
or hard of hearing cite emotional issues and relationships similar to those
involving siblings of children with other disabilities and siblings of children
with no disabilities (Atkins, 1982; Israelite, 1986; Schwirian, 1976). These siblings serve as playmates, companions, friends, protectors, helpers, competitors, rivals, and parent substitutes (Atkins, 1987). In one study, the
relationships of hearing siblings of children with cochlear implants and hearing siblings of children with hearing aids were compared. The findings were
mixed, depending on the birth order of the sibling and the child who was deaf
or hard of hearing, family size, and the technology of the two options (BatChava & Martin, 2002).
Some studies have found that child care and other responsibilities are
higher for siblings of children who are deaf or hard of hearing, but other
studies find no differences. Schwirian (1976) looked at the impact of child care
and general home responsibilities, degree of independence, and extent of
social activities on older siblings of children with a hearing loss and a
matched control group. Older siblings of children who are deaf or hard of
hearing, especially girls, had more childcare duties and general responsibilities as a result of the mother’s increased workload and involvement with the
child who has the hearing loss. However, the extra child care duties did not
impair the older sister’s overall adjustment, suggesting that parental acceptance of a child’s hearing loss and open communication with the siblings can
serve as mediating factors (Schwirian, 1976). Although these older sisters
were less involved in social activities, they were more independent in selfcare tasks than older sisters of hearing children (Schwirian, 1976). Other
studies found that both sets of older sisters spent about the same number of
hours and engaged in the same number of activities with their younger
brother or sister. Older brothers were not mentioned in these studies (Atkins,
1982, McHugh, 1999). A study of siblings of children with cochlear implants
and siblings of children with hearing aids found no gender differences in the
siblings’ responses (Bat-Chava & Martin, 2002).
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Raghuraman
Israelite (1986) assesses the psychological function of female adolescent
siblings of children who are deaf or hard of hearing and siblings of children
with no disabilities regarding family responsibilities, depression, and anxiety.
Compared with siblings of children with no disabilities, siblings of children
who are deaf or hard of hearing have slightly higher scores in family responsibility and depression, and lower scores in anxiety; however, none of the
findings were significant (Israelite, 1986). The findings that responsibility and
child care do not affect the siblings’ well-being contradict those of other
studies, which indicate that the more family responsibilities older siblings
have, the higher their levels of anxiety and depression (Breslau, Weitzman, &
Messenger, 1981).
Siblings of children who are deaf or hard of hearing may face issues such
as perceived parental partiality toward the child with the hearing loss or
inadequate communication with parents. Older siblings may resent the extra
attention that their brother or sister with a hearing loss receives from their
parents, or they may feel that their parents have higher expectations for them
(Atkins, 1987). Older sisters of children who are deaf or hard of hearing feel
that the communication between themselves and their parents is inadequate,
and that their parents expect them to compensate for their brother or sister
with the hearing loss (Atkins, 1982). Older siblings also feel more responsible
for their younger brother or sister with a hearing loss in social situations than
older siblings of children with no disabilities (Atkins, 1982). However, no
group differences were found regarding parental attention, satisfaction with
perceived level of parental attention, and amount of time parents allocated to
these older siblings (Atkins, 1982).
Siblings of children who are deaf or hard of hearing may exhibit many
positive traits, such as greater levels of maturity, tolerance of differences in
other people, empathy, patience, flexibility, and pride in helping their parents
with their brother or sister with a hearing loss (Atkins, 1987). These older
siblings may enjoy being interpreters, role models, helpers, and supporters
and may feel a sense of accomplishment and satisfaction. Many of these
siblings pursue humanitarian or advocacy professions in adulthood (Mindel
& Feldman, 1987).
Method
Participants
The 35 older siblings in each group ranged from 6 to 12 years old, while the
35 children with hearing loss and the 35 children with typical hearing (control
group) ranged from 2 to 7 years old. The participants in the group of older
siblings of children with a hearing loss and the control (hearing) group consisted of an older sibling of a target child. All the parents and siblings in both
groups had typical hearing. The ethnicities of families in the group of children
13
Table 1. Means and Standard Deviations of Demographic Variables (Both Groups)
Gender-Older Sibling
Age-Older Sibling
Gender-Younger Sibling
Age-Younger Sibling
Family Size
# of Siblings
# of People Working
Mother’s Education
Father’s Education
Family Income
Hearing Loss
Hearing
t
p
19M, 16F
8.43 (1.52)
19M, 16F
3.63 (1.31)
4.51 (0.70)
2.57 (0.66)
2.57 (0.85)
2.06 (0.87)
2.34 (1.53)
4.49 (1.90)
19M, 16F
8.43 (1.50)
16M, 19F
3.77 (1.44)
4.60 (0.91)
2.69 (0.93)
2.37 (0.65)
2.45 (1.12)
2.80 (1.32)
5.51 (1.60)
—
0.00
—
−0.44
−0.44
−0.59
1.11
−1.67
−1.34
−2.45
—
NS
—
NS
NS
NS
NS
NS
NS
.05
M = male; F = female
who are deaf and hard of hearing were as follows: Asian (3), African American (2), Caucasian (28), and other (2). The control group consisted of the
following ethnicities: African American (2), Caucasian (32), and other (1).
Using t-tests, the group of older siblings of children with hearing loss and the
control group were matched on gender of both the older sibling and the
younger child; age of older sibling; age of younger child; family size; number
of siblings per family; number of working people in the family; and mother’s
and father’s level of education. No significant differences arose between the
groups on these variables. Only family income was not matched (p < .05). The
group of older siblings of children with a hearing loss had a lower family
income than the hearing group; therefore, all between-group analyses covaried on family income (Table 1).
Procedures
To access participants for the group of children who are deaf or hard of
hearing and the group of children with typical hearing, the investigator first
obtained human subjects approval. Then, by phone and letters, the investigator contacted administrators of local programs serving children with hearing loss and children with typical hearing. The investigator met with the
program administrators in person, provided a flyer describing the project,
and further discussed the study with them. Upon approval, the administrators then contacted families of children with a hearing loss and families of
children with typical hearing who met the criterion of the study. Upon consent from the parents, the administrators then gave the investigator the names
and contact information of the consenting families. While some of these programs also served hearing children, other local schools were contacted to
access a larger pool sample for the control (hearing) group.
Families of children who are deaf or hard of hearing were selected from
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various auditory-oral schools that served that particular population. Some of
the children with hearing loss were mainstreamed one or two days a week in
schools with hearing children. All the families in the group of children with
hearing loss had no history of deafness. The degree of hearing loss ranged
from moderate (25 dB) to profound (90 dB and up); most of the children
falling into the severe-profound range (70–90 dB). All of the children were
learning through listening and spoken language and wore hearing aids, although they also relied on other modes of auditory input and sensory communication (such as visual communication). According to their parents, they
had no other disabilities or medical conditions based on parental reports.
The children with typical hearing in the control group were in the same age
range as the children who are deaf or hard of hearing. The older, hearing
siblings of children who are deaf or hard of hearing and the older, hearing
siblings of the control (hearing) group were recruited from local schools and
daycare facilities in the same area used to select the children with a hearing
loss. All siblings were screened through parent reports for disabilities or
medical conditions. All of the parents and older siblings voluntarily participated in the project.
Home interviews
Families were asked to complete a permission form detailing the nature of
the study and including a request for participation. Confidentiality procedures were strictly followed. Home visits were scheduled with parents and
siblings for evenings and weekends and during holidays. The home visit
lasted about an hour during which time the investigator interviewed the
parents and a research assistant interviewed the siblings. During the home
interviews, two types of data were collected—separate ratings of the parents’
and siblings’ perceptions about the relationship with the younger brother or
sister in both the group of children with a hearing loss and the control group.
Child interview. In the group of older siblings of children who are deaf or hard
of hearing, each sibling was given a consent form, which the parent also
signed. The research assistant then verbally administered the Sibling Perception Questionnaire (SPQ) and the Sibling Relationship Questionnaire (SRQ).
The interview took about 40 minutes to complete, and the children received
a small reward for their participation. The research assistant did not administer the SPQ to the control group, as the questions on this assessment only
apply only to families of children with disabilities.
Parent interview. In the group of older siblings of children who are deaf or hard
of hearing, parents signed a consent form, then filled out a demographics
questionnaire, the Child Behavior Checklist (CBCL) and Social Competence
Scale, the parent versions of the SPQ and SRQ, a temperament questionnaire,
15
and a home routines assessment. The investigator was present while the
parents completed the questionnaires. Total interview time was approximately 60 minutes. The control group parents did not completed the SPQ,
since the questions on this assessment only applied to families of children
with disabilities.
Instrumentation
Instruments in this study included a demographics questionnaire, the
CBCL, the SPQ (parent and sibling versions), the SRQ (parent and sibling
versions), a temperament questionnaire, and a home routines assessment.
Demographics questionnaire
This questionnaire assessed personal and family constellation variables of
families in both groups. Personal information included dates of birth, age,
and gender of both the target child and the older sibling; degree of hearing
loss, rated from mild (25 dB) to profound (90 dB and up); age of child when
diagnosis was made; family size; birth order; level of education for each
parent, rated from high school through doctorate or professional degree;
income range of family, rated from under $30,000 to over $100,000; the number of people earning income outside the home; and other sources of income.
Additional information included any other disabling conditions, such as
physical or psychiatric impairments, in the child or older sibling; any medications being taken; and the type of communication being used.
Families of children with no disabilities answered the same questions, except for degree of hearing loss, age of child when diagnosis was made, and
type of communication.
Psychological variables and parental partiality
Child Behavior Checklist. The CBCL assessed behavior problems and social competence of children 4–16 years old as reported by parents and others who
know the child well (Achenbach, 1991; Achenbach & Edelbrock, 1983; Achenbach, Dumenci, & Rescorla, 2001; Achenbach, Howell, Quay, & Conners,
1991). A highly valid psychometric assessment, the CBCL was normed on
both referred and nonreferred children using a sample of 1,300 children (Dyson, Edgar, & Crnic, 1989). The instrument includes the behavior problems
scale and the social competence scale (described below in the Sibling Activities and Responsibilities section). The CBCL produced a total behavior problem score and a total social competence score with factor and subscale scores.
The behavior problem scale consists of 118 items related to behavior problems, each scored on a 3-point scale: (0) not true, (1) somewhat true, (2) very
true. Factor analysis resulted in two wide-band factors—externalizing and
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internalizing—and nine narrow-band factors, based on the age and gender of
the child: withdrawn behavior, somatic complaints, anxiety/depression, social problems, thought problems, attention problems, delinquent behavior,
aggressive behavior, and other problems. The internalizing factor included
withdrawn behavior, somatic complaints, and anxiety/depression, with item
#103 (sad) removed. The externalizing factor included delinquent behavior
and aggressive behavior (Achenbach, 1991). Scoring was from 0 to 240: The
higher the child’s total score, the more problematic the behavior. Test-retest
reliability ranged from 0.84 to 0.95, while inter-interviewer reliability was
0.96.
Sibling Perception Questionnaire. The SPQ (Sahler & Carpenter, 1989) includes
both a parent version and a sibling version, each consisting of 30 questions.
The sibling version, administered to children ages 6–17 years, assesses two
primary content areas: knowledge about the child’s disability or illness, and
the sibling’s perceptions and affective responses. Responses range from (1)
never to (4) a lot.
The 30 items are clustered into four factors. Factor I (interpersonal concerns, 9 items) looks at the child’s relationships and interactions with others;
for example, “I don’t want to bother my parents with my worries.” Factor II
(intrapersonal concerns, 7 items) focuses on how the disability has affected
the sibling; for example, “I understand why my parents have to spend time
with my brother or sister.” Factor III (communication, 4 items) explores the
sibling’s ability to discuss the disability with others; for example, “I can talk
to my friends about my brother or sister’s problem.” Factor IV (fear of disease,
3 items) looks at the sibling’s fear of “catching” the disease or disability; for
example, “I am afraid of my brother or sister’s illness or disability.” Scoring
ranges from 1 to 120. The internal consistency alpha reliability of these four
factors ranges from 0.65 to 0.86, while inter-rater reliability is 0.85.
The parent version of the SPQ addresses the same issues. The number of
items, the factors, and the scoring are the same. According to Sahler and
Carpenter (1989), no reliability or validity figures are mentioned, as “parents
have been shown to be reliable and valid observers and reporters of their
children’s development, behavior, and psychosocial adaptation” (p. 692).
Sibling Relationship Questionnaire. The SRQ assesses the quality of children’s
relationships with their siblings (Furman & Buhrmester, 1985). Administered
to children ages 6–17 years, the questionnaire consists of 16 dimensions:
prosocial behaviors, maternal partiality, nurturance of sibling, nurturance by
sibling, dominance of sibling, dominance by sibling, paternal partiality, affection, companionship, antagonism, similarity, intimacy, competition, admiration of sibling, admiration by sibling, and quarreling. Responses range from
(1) hardly to (5) extremely.
The 39 items are loaded on four factors. Factor I (warmth/closeness, 15
17
items) includes intimacy, prosocial behavior, companionship, similarity, admiration of and by sibling, and affection; for example, “How much do you
and this sibling love each other?” Factor II (status/power, 12 items) includes
nurturance of sibling, dominance over sibling, dominance by sibling, and
nurturance by sibling; for example, “How much do you tell this sibling what
to do?” Factor III (conflict, 6 items) includes quarreling, antagonism, and
competition; for example, “How much do you and this sibling argue with
each other?” Factor IV (rivalry, 6 items) looks at maternal and paternal partiality; for example, “Who usually gets treated better by your mother, you or
this sibling?” Scoring is by computing the means for each of the factors.
Internal consistency coefficients for all the scales exceeded 0.70, except for the
conflict scale, which was 0.60. Test-retest reliability was 0.71.
Temperament questionnaire. Widely used with parents of children ages 5–12
years, the temperament questionnaire gathers information on the child’s temperament on the basis of how the child behaves and responds to different
situations in everyday life (Keogh, 1986). We used a condensed, revised form
of the original Parent Temperament Questionnaire (PTQ) (Keogh, 1986;
Thomas & Chess, 1977). This questionnaire includes 23 of the original 72
items, representing dimensions of activity level, approach/withdrawal,
adaptability, distractibility, intensity, persistence, quality of mood, and
threshold of response. Rhythmicity was not included.
The scales are grouped into four factors. Factor I (approach/withdrawal/
adaptability/distractibility, 11 items) asks questions such as “My child is shy
with adults he/she does not know.” Factor II (intensity/threshold, 7 items)
asks questions such as “My child seems to take things matter-of-factly and
accepts events in stride without getting very excited.” Factor III (mood, 3
items) looks at elements such as “When with other children, my child seems
to be having a good time”; “When playing with other children, my child
argues with them” (scoring reversed); and “If a favorite toy or game is broken, my child gets noticeably upset” (scoring reversed). Factor IV (persistence, 2 items) looks at items such as “My child gets involved in quiet
activities such as crafts, watching television, reading, or looking at picture
books.”
The items are rated on a 6-point scale from (1) hardly ever to (6) almost
always. Scoring is reversed for 9 of the 23 items. Scoring is calculated by
computing the means for each of the four factors. Dimension scores can also
be obtained by computing the means for each of the seven dimensions: approach/withdrawal, adaptability, mood, intensity, threshold, persistence,
and distractibility. We computed a score for “easy–difficult temperament”
using the dimension scores. Reliability coefficients for the factors ranged from
0.62 to 0.94. Test-retest reliability was 0.81 and inter-rater reliability was 0.59.
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Sibling activities and responsibilities
Social Competence Scale. This second portion of the CBCL looks at the child’s
activities, social interactions, and academic performance compared with that
of peers (Achenbach & Edelbrook, 1983; Achenbach et al., 1991; Achenbach et
al., 2001). The Social Competence Scale was answered by parents of children
between 4 and 16 years old.
The scale has three factors with a total of 20 items. Factor I (activities, items
I, II, IV) looks at the child’s (sibling’s) competence and the amount of time
spent in sport and nonsport activities and responsibilities, rated from (1)
don’t know to (4) more than average. For example, parents listed the sports
that their child liked to participate in the most. Factor II (social interactions,
items III, V, VI) included the degree of participation in activities and organizations, rated from (1) don’t know to (4) more active; number of friends, rated
from (1) none to (4) four or more; and behavior, rated from (1) worse to (3)
better. For example, “Does the child get along with his/her brothers and
sisters?” Factor III (school, item VII) looks at school performance; for example,
whether the child is in a special education class or has repeated a grade. The
first question is rated from (1) failing to (4) above average. The next three
questions are rated as (1) no or (2) yes. Scoring ranges from zero to 30: 0–12
each on the activities and social interactions scales and 0-6 on the school scale.
Test-retest reliability was 0.97, while inter-interviewer reliability was 0.92.
Home routines assessment. This assessment looked at household and child care
tasks, rights and privileges, and social activities that the sibling was involved
in outside the home (Schwirian, 1976). The assessment consists of 51 items; it
was completed by parents of siblings between the ages of 7 and 16 years.
There are three factors. Factor I (child care tasks/household responsibilities, 27 items) relates to household duties and care of the younger sibling.
Reponses range from (0) never to (3) most of the time. The three childcare
subdomains are babysitting, sibling monitoring, and helping with day-to-day
physical care; for example, “Entertains younger child while you are at home.”
The four household subdomains are personal and self-care tasks, meal preparation, cleaning the house, and outside tasks; for example, “Does the child
dress the younger sibling?” Scoring ranges from zero to 81.
Factor II (rights/privileges, 18 items) looks at the degree of independence
and privileges a sibling has, such as having a set bedtime or visiting with
friends on weekdays. Eleven items are rated (0) no or (1) yes, while the rest
of the items are rated according to the question. For example, (0) no to (3)
always, for a set bedtime on school nights; (1) friend’s mother to (5) other, for
who reminds a sibling who is visiting a friend when it is time to return home;
and (1) himself/herself to (4) does not do leisure reading, for who selects
leisure reading material for the sibling. Scoring ranges from 0 to 35.
19
Factor III (social activities, 6 items) assesses the frequency of participation
in social activities, rated by the number of hours spent in that activity per
week from (0) none to (2) over six hours. Other questions are rated as (1) no
or (2) yes. Activities are divided into four categories: sports, music, clubs, and
church. For example, “How many close friends does the child have?” Scoring
ranges from 0 to 21. This instrument had a test-retest reliability of 0.89 to 0.98.
Results
Data Analysis
This research study analyzed for group and gender differences between
older siblings of children who are deaf or hard of hearing and older siblings
of children with normal hearing on dependent variables. A second analysis
examined parent versus sibling ratings on the SPQ and the SRQ to assess the
degree of concordance. Third, within-group analyses looked at relations
among variables within the group of older siblings of children who are deaf
or hard of hearing.
Differences due to group and gender
None of the predicted between-group differences were significant; however, there were significant between-gender findings. Significant main effects
by gender appeared in communication, status/power, social problems, and
attention problems. Since the groups differed on family income, we conducted analyses of covariance with family income taken into consideration.
Psychological variables. In contrast to predictions, a 2 (group) × 2 (gender) analysis of covariance (ANCOVA) (with family income as the covariate) showed
that older siblings of children with hearing loss did not differ from older
siblings of hearing children on conflict, warmth/closeness, interpersonal concerns, and depression, nor were there any differences between boys and girls
or any interaction effects.
Perceived parental attention. Contrary to predictions, a 2 (group) × 2 (gender)
ANCOVA (family income as covariate) showed no differences between older
siblings of children with hearing loss and older siblings of hearing children on
parental attention, nor did boys and girls differ. There were no interaction
effects.
Sibling activities and responsibilities. A 2 (group) × 2 (gender) ANCOVA (with
family income as covariate) revealed that older siblings of children with
hearing loss did not differ from older siblings of hearing children on child
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care tasks and household responsibilities. Boys and girls did not differ, nor
were there any interaction effects.
Other findings
Gender differences. On parent ratings of the SPQ, only one of four domains was
significant. A 2 (group) × 2 (gender) ANCOVA (with family income as covariate) indicated that parents believed that older sisters showed fewer communication problems than older brothers: F (1, 34) = 10.79, p < 0.01. Parent
ratings were not significant on the other three domains of the SPQ: interpersonal concerns, intrapersonal concerns, and fear of disease. None of the sibling ratings on this questionnaire were significant for all four domains.
On parent ratings on the SRQ, status/power was the only significant domain of the four. A 2 (group) × 2 (gender) ANCOVA (with family income as
covariate) indicated that parents believed that older sisters showed more
status/power than older brothers: F (1, 69) = 8.07, p < 0.01. Parent ratings
were not significant on the other three domains—warmth/closeness, conflict,
and rivalry—nor were any of the sibling ratings significant across all four
domains of the questionnaire.
On parent ratings of the CBCL, a 2 (group) × 2 (gender) ANCOVA (with
family income as covariate) showed that only two of the nine narrow-band
factors on this assessment were significant. Parents believed that older brothers showed more social problems and more attention problems than older
sisters: F (1, 69) = 5.51, p < 0.05 and F (1, 69) = 4.85, p < 0.05. The other seven
factors were not significant. ANCOVAs of the wide-band factors—
externalizing and internalizing—were not significant.
Parent and sibling ratings
Differences between parent and sibling ratings on the SPQ and the SRQ
were assessed using paired t-tests. In the group of older siblings of children
who are deaf or hard of hearing, only one domain of the SPQ was significant:
interpersonal concerns, t = −6.34, p = 0.000. The means and standard deviations, respectively, for the parent and sibling ratings were 22.57 (4.12) and
17.60 (4.09). Parents of children with hearing loss had higher ratings on this
domain than the older siblings, suggesting that parents thought the older
siblings had more interpersonal concerns than the older siblings themselves
did.
Further analyses of the individual items comprising the interpersonal concerns domain on the SPQ showed that seven of the nine questions in this
domain were significant (Table 2). Older siblings of children with a hearing
loss rated two items more highly than their parents did: “I don’t want to
bother my parents with my worries” and “I have too much to do in the house
because of my brother/sister” (Table 2).
21
Table 2. Parent and Sibling Ratings of the SPQ Interpersonal Concerns Domain
(Older Siblings of Children With Hearing Loss)
I don’t want to bother my parents with my
worries.
I have too much to do in the house because
of my brother/sister.
I wish I knew someone who understands
how I feel.
I wish my parents would spend less time
with my brother/sister.
I wish my parents would spend more time
with me.
My parents ignore me.
People are more interested in my
brother/sister than in me.
People don’t care how I feel.
My brother’s/sister’s problem changes
what we can do as a family.
Sibling
Parent
t
p
3.26 (0.86)
2.44 (0.79)
4.03
0.000
2.23 (1.03)
1.80 (0.80)
2.32
0.05
2.80 (1.08)
2.51 (0.92)
1.44
NS
1.60 (0.88)
2.77 (0.81)
−7.51
.000
2.09 (1.17)
3.09 (0.66)
−4.98
0.000
1.60 (0.81)
2.11 (1.02)
2.51 (0.66)
2.49 (0.86)
−5.35
−1.60
0.000
NS
1.46 (0.74)
1.91 (0.95)
2.34 (0.80)
2.49 (0.98)
−4.63
−2.12
0.000
0.05
Ratings range from 1 (never) to 4 (usually)
Parents of children with hearing loss rated the following items on the
parent version of the SPQ more highly than the siblings did on their version
of the questionnaire: “I wish my parents would spend less time with my
brother/sister”; “I wish my parents would spend more time with me”; “My
parents ignore me”; “People don’t care how I feel”; and “My brother’s/
sister’s problem changes what we can do as a family.” Parents seemed to
think the older sibling wanted more time with them and less time with the
child who has a hearing loss, that the older sibling perceived that he or she
was being ignored by the parents, that other people appeared to not care how
the older sibling was feeling, and that having a child with hearing loss
changed what the family could do. However, the older siblings appeared not
to feel as strongly about these items as the parents thought they did (Table 2).
The three remaining domains on the SPQ—intrapersonal concerns, communication problems, and fear of disease—were not significant. In addition,
none of the parent-sibling ratings on the four domains of the SRQ—warmth/
closeness, status/power, conflict, and rivalry—were significant in either
group.
Within-group relations
In this section, correlations within the group of older siblings of children
who are deaf or hard of hearing and the control group are discussed as well
as differences in correlations between groups.
22
Raghuraman
Table 3. Correlations Between Temperament and the CBCL (Both Groups)
Temperament
Withdrawn Behavior
HL
H
Somatic Complaints
HL
H
Anxiety/Depression
HL
H
Social Problems
HL
H
Thought Problems
HL
H
Attention Problems
HL
H
Delinquent Behavior
HL
H
Aggressive Behavior
HL
H
Other Problems
HL
H
0.54***
0.43**
0.26
0.27
Z
0.59
−0.04
0.60***
0.16
2.17*
0.67***
0.22
2.40*
0.44**
0.00
1.93
0.54***
−0.04
0.17
0.29
2.63**
−0.52
0.58***
0.27
1.57
0.60***
0.48**
0.69
HL = hearing loss; H = hearing
* p < 0.05; **p < 0.01; *** p < 0.001
Temperament and child behavior. Within-group relations appeared between temperament and the domains of the CBCL. Parents of children with hearing loss
believed that older siblings who had a more difficult temperament showed
more externalizing behaviors (aggressive behavior and delinquent behavior)—HL: r = .53, p < 0.001; H: r = .30, p < 0.05. Specifically, older siblings who
had a more difficult temperament showed more behavior problems on seven
of the nine narrow-band factors of the CBCL (Table 3).
Comparing the correlations in both groups, older siblings who had a more
difficult temperament expressed more internalizing behaviors (withdrawn
behavior, somatic complaints, and anxiety/depression)—HL: r = .63, p <
0.001; H: r = .36, p < 0.05. They also had a higher total score—HL: r = .67,
p < 0.001; H: r = .34, p < 0.05.
23
Table 4. Correlations Between Age-Spacing and Parent Ratings of the SRQ
(Both Groups)
Age-Spacing
Warmth/Closeness
HL
H
Status/Power
HL
H
Conflict
HL
H
Rivalry:
HL
H
Z
0.13
0.04
0.37
0.41*
−0.07
2.06
−0.49**
−0.34*
−0.74
−0.26
−0.16
−0.43
HL = hearing loss; H = hearing
*p < 0.05; **p < 0.01; ***p < 0.001
Age-spacing. On parent ratings of the SPQ, only two of the four domains were
significant. Parents believed that older siblings of children with hearing loss
showed fewer interpersonal concerns and less fear of disease—r = −.35, p <
0.05 and r = −.42, p < 0.01. The other two domains—intrapersonal concerns
and communication problems—were not significant, nor were any of the
sibling ratings for any of the four domains on the SPQ.
On parent ratings of the SRQ, two of the four domains—status/power and
conflict—were significant. Comparing correlations in the hearing loss and
control groups, parents believed that older siblings showed less conflict and
more status/power as age-spacing increased (Table 4). Parent ratings of the
other two domains of the SRQ—warmth/closeness and rivalry—were not
significant, nor were any of the sibling ratings across all four domains.
Perceived parental attention. Contrary to expectations, there were no significant
correlations between parental attention and warmth/closeness, conflict, depression, or interpersonal concerns. There were also no significant correlations between parental attention and degree of hearing loss.
Sibling activities and responsibilities. Contrary to expectations, there were no
significant correlations between family income and child care tasks or household responsibilities.
Other findings
Hearing loss. An unexpected finding emerged between hearing loss and the
behavior domains of the CBCL. In the group of older siblings of children who
24
Raghuraman
Table 5. Correlations Between Hearing Loss and Parent Ratings of the CBCL
(Hearing Loss Group)
Hearing Loss
Withdrawn Behavior
Somatic Complaints
Anxiety/Depression
Social Problems
Thought Problems
Attention Problems
Delinquent Behaviors
Aggressive Behaviors
Other Problems
0.42**
0.07
0.33
0.34*
0.26
0.58***
0.49**
0.52***
0.33
*p 0.05; **p < 0.01; ***p < 0.001
are deaf or hard of hearing, as the severity of the younger child’s hearing loss
increased, older siblings showed fewer behavior problems. Older siblings of
children with more severe hearing loss showed less internalizing behavior (r
= −.37, p < 0.05) and less externalizing behavior (r = −.56, p < 0.001), and the
total behavior score also decreased (r = −.52, p < 0.001).
The connection between the younger child’s severity of hearing loss and
the older sibling’s behavior problems occurred in five of the nine narrowband factors of the CBCL: withdrawn behavior, social problems, attention
problems, delinquent behavior, and aggressive behavior. The other four narrow-band factors—somatic complaints, anxiety/depression, thought problems, and other problems—were not significant (Table 5).
Positive and negative feelings. In the group of older siblings of children who are
deaf or hard of hearing, siblings’ ratings were significant for only one of the
four domains of the SPQ. Older siblings who perceived positive relations
with their younger brother/sister with a hearing loss showed fewer interpersonal concerns: r = −.62, p < 0.001. Conversely, older siblings who perceived
more negative relations with their younger sibling with a hearing loss demonstrated more interpersonal concerns: r = .54, p < 0.001. Sibling ratings of the
other three domains of the SPQ—intrapersonal concerns, communication
problems, and fear of disease—and parent ratings for all four domains were
not significant.
In both the hearing loss and control groups, sibling ratings on the SRQ were
significant in only one of the four domains—warmth/closeness. Older siblings who related more positively toward the younger child expressed more
feelings of warmth/closeness (HL: r = .49, p < 0.01; H: r = .50, p < 0.01). In
contrast, older siblings in both groups who had more negative feelings about
relations with the younger child expressed less warmth/closeness (HL: r =
−.49, p < 0.01; H: r = −.40, p < 0.05). Sibling ratings of the other three domains
25
of the SRQ—status/power, conflict, and rivalry—and parent ratings for all
four domains were not significant.
Discussion
This study sought to acquire further information about the emotional wellbeing of older siblings of children who are deaf or hard of hearing and
children with no disabilities. Three main findings emerged. First, the results
do not match those of previous studies that suggest a negative effect of a
disability on sibling relationships (Atkins, 1987; Dyson et al., 1989; Lobato et
al., 1987). Second, parental perceptions of sibling relationships appear to concur with sibling perceptions, with the exception of interpersonal concerns.
Third, parental perceptions of temperamental difficulty and behavior problems among older siblings seemed greater when the younger child (in the
hearing loss group) had a less severe hearing loss.
Siblings of Children With Hearing Loss and Hearing Children
In this study, older siblings of children with no disabilities and older siblings of children who are deaf or hard of hearing reflect a similar spectrum of
positive and negative feelings regarding the sibling relationship (Atkins,
1982; Cicirelli, 1985; Dyson et al., 1989; Meadow-Orlans, 1990; Stoneman &
Berman, 1993). The lack of group differences on the psychological variables,
parental attention, and household responsibilities/child care tasks suggests
that mediating factors—such as parental availability, degree of parental adjustment, and communication—may have lessened the impact of having a
child with a hearing loss (Bat-Chava & Martin, 2002; Cicirelli, 1995; MeadowOrlans, 1990; Schwirian, 1976; Stoneman & Berman, 1993).
Older siblings may come from families where the parents have adjusted
and adapted the family dynamics to meet the needs of the child with hearing
loss as well as the other family members. For example, if parents are intensely
involved in meeting the needs of the child with a hearing loss, they may be
including the older sibling or doing other activities with him or her in a way
that allows the older sibling to feel as though he or she is receiving sufficient
parental attention (Cicirelli, 1995; Stoneman & Berman, 1993). Parents may
purposely not be giving the older sibling too many responsibilities, to prevent
feelings of being overburdened, or they may assign responsibilities that the
older sibling welcomes and that make him or her feel important in the family
(Atkins, 1987). In addition, if the siblings have been involved in support
networks, their adjustment could be more positive (Dyson, 1998).
Another possible explanation for the lack of group findings is the developmental phase of the older siblings. It is possible that during these elementary years, older siblings are more flexible and accepting of a brother or sister
26
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who is deaf or hard of hearing. These same older siblings might feel differently in adolescence. The social stigma that some studies have found could be
due to the extent of interaction between an older sibling and the child with
hearing loss in public, with friends, or in a mainstreamed environment (Boyce
& Barnett, 1993; Gath, 1974; McHale et al., 1986). An adolescent may feel more
self-conscious than an elementary-age older sibling about being around a
brother or sister with hearing loss.
Older siblings who are adults may have feelings and perspectives that were
not present during childhood or adolescence, or that changed over time. For
example, they may start to worry about who will take care of the child who
is deaf or hard of hearing if something happens to their parents or, when they
are ready to start their own families, they may wonder if the hearing loss
might be passed on to their children (Meadow-Orlans, 1990; Mindel & Feldman, 1987). It would be interesting to follow these older siblings throughout
their adolescence and into adulthood to evaluate how their perceptions and
relationships with their younger siblings mature and change over time.
In this research study, older sisters in both groups show more positive
interactions with their younger siblings than older brothers in both groups.
These findings are typical of studies showing that girls tend to be more
empathic, nurturing, warm and open, and easier to communicate with than
boys (Atkins, 1982; Boer & Dunn, 1992; Brody et al., 1987). It is possible that
gender influenced findings in previous studies that examined relationships
between children with no disabilities and their siblings with disabilities, including hearing loss (Atkins, 1987). For example, one study in which no
group differences were found included only older sisters (no brothers) in both
the hearing loss and hearing (control) groups (Israelite, 1986). Findings that
may actually be gender-specific could have accounted for group differences
or lack of differences.
Parent and Sibling Ratings Regarding Sibling Concerns
Although both parent and child ratings were included in the findings,
analyses showed no significant differences between parent and child ratings
on three domains of the SPQ and on all four domains of the SRQ. The only
significant domain on the SPQ was interpersonal concerns. Parents perceived
that older siblings had more concerns than the older siblings themselves
reported. Analyses of the individual items in this domain showed that older
siblings did not feel as strongly as their parents on most of the items regarding having a brother or sister with a hearing loss. It is possible that parental
perceptions were influenced by their own feelings about having a child with
a hearing loss and the changes they may have had to make to accommodate
the needs of the child (Meadow-Orlans, 1990). They may have unintentionally
projected their own feelings on the older siblings when, in reality, the older
siblings did not feel strongly on these issues.
27
However, older siblings of children with hearing loss seemed to believe,
more than their parents, that they had too much to do in the house because
of their brother/sister. It is possible that the older sibling was expected to do
more simply because he or she was older. This perception may be no different
from that of the control group, where older siblings of children with no
disabilities may also have had more duties around the house. The absence of
group differences on household responsibilities supports this explanation.
Older siblings of children who are deaf or hard of hearing also felt more
strongly than their parents that they did not need to always bother their
parents with their worries. It is possible that the parents thought the older
siblings had more worries about having a brother or sister with a hearing loss,
while the older siblings themselves either did not have these worries or were
not much bothered by them. On the other hand, older siblings may have such
concerns but may not want to share them with their parents because they do
not want to worry them or they do not know how to express their worries
(Cicirelli, 1995; Crnic & Leconte, 1986). The developmental age of the older
siblings also could play a role. If the siblings had been older, maybe adolescents, they might have had more worries or been more likely to express their
worries to their parents (Meadow-Orlans, 1990; Mendel & Feldman, 1987).
Since the control group did not answer the questions on the SPQ, it is not
possible to make comparisons between the two groups.
Although older siblings and their parents are both dealing with a child who
is deaf or hard of hearing, they may have their own ways of responding and
adapting. The lack of differences on most of the parent and sibling ratings
appears to reflect accurate parental perceptions about their children. The fact
that older siblings differed from their parents in only one domain—
interpersonal concerns—suggests that having a brother or sister with a hearing loss may not be as difficult for older siblings as parents might think.
Variables Leading to Increased Problems in the Hearing Loss Group
Parental perceptions may also have affected the findings on temperament
and behavior in relation to the degree of hearing loss. As the severity of
hearing loss increased, older siblings of children with a hearing loss showed
fewer behavior problems. A possible explanation is that the less severe the
hearing loss, the more difficult it can be to detect. The child with a less severe
hearing loss might be able to hear some things but not hear other things as
well or at all. This situation can be confusing and bewildering for an older
sibling who does not fully understand the nature of the hearing loss, or of any
disability of a mild nature (Stoneman & Berman, 1993; Tew & Lawrence,
1973). If the older sibling does not understand or cannot adequately express
his or her feelings about the situation (as is typical of very young children),
he or she may react by showing more behavior problems. When the hearing
loss is more severe, the situation is more clear-cut for everyone. Parents may
28
Raghuraman
understand more about the hearing loss and may be able to help the older
sibling understand how to interact and communicate with the child with the
hearing loss.
Communication is an important variable that needs further analysis. Although all the children in the hearing loss group attended schools that taught
them to listen and speak, the quality of communication should be further
assessed. For example, one could look at the child who has a hearing loss in
the context of family, including how communication occurs between the parents and the child and between the child and his or her siblings. More information is also needed on “speaker” and “listener” roles, and how the hearing
family members and the child with the hearing loss understand each other
(Lloyd, 1999). The findings of this study are limited to this population of older
siblings of children who are deaf or hard of hearing—different communication styles could be further assessed.
Children who are deaf or hard of hearing are receiving cochlear implants
more rapidly than hearing aids. Many children who meet the criteria for
cochlear implants receive them, while children with less severe hearing losses
do just as well with hearing aids. It would be interesting to explore the
communication patterns between families of children with cochlear implants
and those of children with hearing aids. One could also look at the emotional
well-being of older siblings of children with cochlear implants and older
siblings of children with hearing aids. Bat-Chava and Martin (2002) spent
time with parents of children with cochlear implants and hearing aids in an
effort to understand sibling relationships. They found a slightly more positive
trend among siblings of children with cochlear implants. However, they point
out that this finding might simply be due to the fact that their sample of
children with cochlear implants was larger than their sample of children with
hearing aids. No other findings were significant.
Temperament is another factor that appeared to influence sibling dynamics. It is possible that a positive temperament helped the older siblings adapt
to having a brother or sister with a hearing loss and develop a relationship
with him or her. Older siblings with a difficult temperament were more likely
to exhibit low intensity, low adaptability, negative mood, and low persistence. Studies show that older siblings who display high persistence in completing a task or an activity and low emotional intensity show less agonistic
behavior (Brody et al., 1987). Older siblings of children with a hearing loss
who showed a difficult temperament exhibited more behavior problems.
Siblings’ perceptions of their own behavior and temperament in relation to
having a brother or sister who is deaf or hard of hearing reflect the accuracy
of parental responses. Older siblings of children with a hearing loss may view
their behavior and temperament differently from the way their parents view
them, or they may share similar views. Using an equivalent measure of the
CBCL and the temperament questionnaire for siblings might be helpful. Also,
having parents complete the temperament questionnaire with regard to
29
themselves and the younger, target child rather than just for the older sibling
may reveal additional information about sibling perceptions and relationships. It is possible that the individual temperaments of both the parent and
the target child influence parental attitudes, degree of adjustment to the hearing loss, and parental perceptions of the older sibling’s and the target child’s
behavior.
Answers from a single respondent could influence the relationship among
hearing loss, temperament, and behavior problems. Mothers were the primary parental respondents in this study. If a mother believed that the older
sibling had a difficult temperament, she may have also believed that he or she
had more behavior problems when in reality the older sibling did not. The
responses might have differed if both parents had actively participated in the
assessments or if fathers had been the primary respondents.
Another crucial variable to assess in future studies is the effect of culture
and ethnicity on sibling perceptions and relationships (Dunn, 2005). No studies looked solely at the impact of ethnicity on families who have children with
a hearing loss. The study by Bat-Chava and Martin (2002) has a more diverse
sample than past studies, although the majority of participants are Caucasian.
It would be interesting to include a wide range of families from diverse ethnic
backgrounds to try to understand the impact of ethnicity and culture on
families of children who are deaf or hard of hearing.
Other methods of acquiring information on sibling perceptions and relationships might include looking at family stress to see if high levels of stress
result in more behavior problems or temperamental difficulties in children
and, thus, influence parental perceptions. One study found that siblings
showed more behavior problems and conflict when their parents had higher
levels of stress (Feinberg et al., 2005). In another study, the behavior problems
were even more obvious when the parents had a negative perception of the
disability (Dyson et al., 1989). Having a larger sample might also balance
family income, ruling out the need to control this variable in interpreting the
results. Despite analyses showing no significant differences between the two
groups on level of maternal and paternal education, lower family income in
the hearing loss group may have been due to one parent staying home with
the child with the hearing loss.
Conclusion
The multimethod approach used in this study highlights the need for a
better understanding of sibling perceptions and relationships. Unlike previous studies on sibling perceptions and relationships in populations with disabilities, this study expands existing research by having a larger sample,
including both brothers and sisters and the perspectives of both older siblings
and their parents. Because of the scarcity of literature on siblings of children
who are deaf or hard of hearing, it is important to further evaluate the range
30
Raghuraman
of positive and negative feelings of siblings of children with a hearing loss,
siblings of children with other disabilities, and siblings of children with no
disabilities. As Minuchin (1974) says, siblings play a crucial role in the family,
and researchers need to pay much closer attention to their contributions to the
family system of children who are deaf or hard of hearing.
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35
Reading Comprehension of an
Inferential Text by Deaf
Students With Cochlear
Implants Using Cued Speech
Santiago Torres, Ph.D, José-Miguel Rodríguez, Ph.D.,
Javier García-Orza, Ph.D., and Marina Calleja, Ph.D.
The aim of this study was to explore the ability of children who are profoundly deaf
to reach high levels of reading proficiency on an inferential reading task. In an
experimental narrative reading task, four children with prelingual hearing loss who
used cued speech (MOC group) were compared with 58 students with typical hearing: 30 peers at the same chronologic age (CA group) and 28 students at the same
reading level (RA group). The MOC group performed similarly to the RA group.
Cued speech (CS), used jointly with a cochlear implant (CI), seems to provide students who are deaf or hard of hearing with an additional support that helps them
achieve high performance levels in reading comprehension.
Introduction
The subject of how high-level reading skill acquisition can transform a child
with hearing loss into an autonomous pupil is widely studied, but many
questions still remain (Bresson, 1996; Harris & Beech, 1995; Kyle & Woll, 1985;
Lichtenstein, 1998; Marschark & Harris, 1996; Paul & Jackson, 1994).
Several studies have shown that, after finishing compulsory education,
Santiago Torres, Ph.D., is a full time professor in the Department of Basic Psychology and
Director of the MOC Research Group, University of Málaga, Spain. José-Miguel Rodríguez,
Ph.D., is a Professor in the Department of Basic Psychology and a member of the MOC
Research Group, University of Málaga, Spain. Javier García-Orza, Ph.D., is a Professor in the
Department of Basic Psychology and a member of the MOC Research Group, University of
Málaga, Spain. Marina Calleja, Ph.D., is a Professor in the Department of Basic Psychology
and a member of the MOC Research Group, University of Málaga, Spain. Correspondence
concerning this article should be addressed to Santiago Torres, Ph.D., Department of Basic
Psychology, Campus de Teatinos, University of Málaga, 29071 Málaga, Spain or by email to
[email protected].
Reading Comprehension of an Inferential Text
37
students who are deaf or hard of hearing (mean age 17 years) have reading
levels similar to or lower than the reading levels of students with typical
hearing in the fourth grade (mean age 9 years) (Conrad, 1979; Torres &
Santana, 2005). The mean scores of a sample of pupils with hearing loss used
as the normative value in the 9th edition of the Stanford Achievement Test
(SAT) did not reach the most basic level in that test (Traxler, 2000). This group
could be situated between the third and fourth academic grade. The 80th
percentile for this sample is comparable to the basic or below-basic performance level of people with typical hearing. Some young people with hearing
loss have performed similarly to young people with typical hearing, although
such good results diminish with age (Traxler, 2000). Previous studies have
shown similar results (Holt, 1993; Holt, Traxler, & Allen, 1996). The best
results (Geers & Moog, 1989; Lewis, 1998) have been attributed to excellent
competence in English oral language.
Skilled reading is the ability to derive meaning from a text accurately and
efficiently. To attain a high level of skill, novice readers must, through instruction and practice, acquire two sets of abilities that are often studied
separately but that actually develop and operate interactively. First, to recognize printed words, children must become aware that spoken words are
composed of smaller elements of speech (phonological awareness), grasp the
idea that letters represent these sounds (the alphabetic principle), learn the
many systematic correspondences between sounds and spellings (decoding),
and acquire a repertoire of highly familiar words that can be recognized on
sight (word recognition). Second, to acquire strong reading comprehension
skills, children must develop the necessary knowledge base to understand the
messages conveyed by connected text. This includes background knowledge
of facts and concepts, a broad and deep vocabulary, familiarity with syntactic
and semantic sentence structures, verbal reasoning abilities, and knowledge
of literacy conventions.
Becoming a skilled reader requires the development of all these components, not in isolation but interactively. Decoding, for example, depends on
understanding and using the alphabetic principle, which in turn depends on
phonological awareness. As a means to word recognition, however, decoding
a letter string is of little value unless the pronunciation the child arrives at can
be paired with the pronunciation of a word the child already knows in spoken
form. Similarly, sophisticated comprehension strategies are of little aid in
interpreting the passage unless the child can successfully recognize most of
the words. Thus, a low score in a text comprehension measure can result from
weak comprehension abilities, slow or inaccurate word recognition skills, or
both. For a review of scientific research on the reading process and its acquisition, see the report of the Committee on the Prevention of Reading Difficulties of the National Research Council (Snow, Burns, & Griffin, 1998).
38
Torres, Rodríguez, García-Orza, & Calleja
Literacy and Children with Hearing Loss:
The Language Question
A widely accepted point of view in the reading skills acquisition field is
that the reading process evolves more easily when oral language is well
consolidated (Dickinson & MacCabe, 2001). The role of oral language in the
education of people who are deaf or hard of hearing has been widely analyzed.
Reading skills acquisition is hindered by problems and delays in oral language acquisition. Hearing loss often results in atypical development of oral
language (see Marschark & Harris, 1996, for a review). Children with hearing
loss have limited knowledge regarding the representation of oral language in
written language. Even though most people with hearing loss can develop
communication skills at a functional level using other communicative modalities, such as sign language, the lack of linguistic competence is a critical
problem in access to literacy. Goldin-Meadow and Mayberry (2001) stated
that the first step in helping a child with a hearing loss become a skilled
reader is to ensure that he or she has well-developed language. Children will
never learn to read unless they have a language from which they can directly
transfer written codes. Whatever kind of language the child has learned
(signed or oral), this will encourage him or her to read even if the language
does not exactly map onto the one represented in written texts. However, it
seems that phonological encoding skills are necessary to achieve high reading
levels (Alegría, 2004). These skills allow the child to match the written language to his or her own communicative modality. In addition, phonological
decoding skills are mainly extracted from oral language.
In conclusion, mastery of a language is a prerequisite for children with
hearing loss to gain access to reading abilities. Linguistic competence will
include decoding skills, lexical access skills, and semantic and syntactic processing skills. These skills facilitate the comprehension of the messages conveyed by connected text, which also includes background knowledge of facts
and concepts.
Access to Literacy Through the Use of Cued Speech and
Cochlear Implants
Cued speech (CS) is a simple oral-based system composed of a limited
series of hand complements used along with the lip patterns of normal
speech. The CS system was created by R. Orin Cornett in 1967 as a form of
oral communication between children with hearing loss and their parents,
mainly during the development of speech and speechreading skills (i.e., in the
early years). In CS, two components—hand complements and speechreading—
provide a nonambiguous visual representation of speech (Cornett, 1967;
39
Torres & Ruiz, 1996, for the Spanish version of CS). The main difference
between CS and other manual systems is the hand complements. A hand
complement consists of two parameters—hand position and hand shape—
that are perceived simultaneously with lip movements. On their own, hand
complements do not offer a unique or specific meaning; rather, they provide
cues for speechreading. Hand shapes are intended to clarify consonants and
hand positions to clarify vowels; they are produced simultaneously with
speech at the same rate.
The CS system was specifically designed to take advantage of certain
speech features, such as decoding of vowels and consonants. The system
provides children who are deaf or hard of hearing with adequate linguistic
competence and phonological decoding skills to enable them to successfully
cope with the reading acquisition process.
In the past two decades, many studies have shown the potential of this
system to help people with hearing loss achieve linguistic competence, master
a language, and achieve good reading ability. Important studies have demonstrated that CS improves linguistic development (see Hage & Leybaert,
2006, for a review); speech intelligibility (Descourtiex, Groh, Rusterholtz, Simoulin, & Busquet, 1999; Vieu et al., 1998); cognitive processing (Charlier &
Leybaert, 2000); and linguistic aspects such as phonology, syntax, and grammatical vocabulary (Santana, Torres, & Garcia, 2003). Regarding speech input,
the natural process of verbal learning is restored by using CS at home
(Moreno-Torres & Torres, 2008; Torres, Moreno-Torres, & Santana, 2006).
In addition, the widespread use of cochlear implants (CI) in the past 10
years has radically changed the scope of the systems and methods used to
develop spoken language of persons who are deaf or hard of hearing. CIs
have become strongly allied with oral-auditory philosophy and the combination has begun to yield interesting results, mainly in children who received
implants at 3 years of age or younger (see Geers, 2006; Nicholas & Geers,
2006, for a review).
Several studies have investigated the level of linguistic competence
achieved by children who receive a cochlear implant very early (Spencer,
2004; Svirsky, Lynne, Ying, Lento, & Leonard, 2002; Szagun, 2004). The results
of these studies (which were carried out primarily in clinical environments)
suggest that CIs are the solution to the problem of oral language skill acquisition among people with hearing loss. However, although CIs are considered
to be extremely advantageous, some caveats remain.
Mukari and colleagues (2007) analyzed the educational performance of 20
pediatric cochlear implant recipients who attended mainstream classes and
compared their performance with that of their hearing peers. Mukari and
colleagues used three measures to assess school performance: a teacher rating
scale, the child’s test results, and the child’s standing compared with that of
his or her peers in language studies and mathematics, as well as overall
academic performance on end-of-semester tests. On the teacher rating scale,
40
only 11.8% of the children were not rated as educationally at risk. On educational performance, the CI recipients performed significantly better in
mathematics (mean score 62.67%) than in language (mean score 49.96%). In
overall test performance, 25% had above-average performance (>75th percentile); 18.75% had average performance (25-75th percentile); and 56.25%
had below-average performance (<25th percentile). The authors conclude that
it is possible that language deficit presents an educational challenge for the
children with CIs. The educational performance of children with CIs varied in
mainstream classes. Although 43.75% thrived in a full-time mainstream setting, a significant percentage performed at a below-average level. These findings support the idea that although CIs provides recipients with the potential
for good hearing, most recipients still require extra support to function well
in the educational setting.
Mukari and colleagues (2007) show that the acquisition of oral language
and, thus, the acquisition of literacy, are not fait accompli, despite the fact that
CIs have become technologically more advanced and younger children are
receiving implants. Questions remain about how to support oral language
development after receiving a CI and how to help children with hearing loss
achieve linguistic competence and become skilled readers.
To answer these questions, it is worth analyzing the impact of combining
CIs and CS, which has led to advances in language acquisition among people
who are deaf or hard of hearing in recent years. On the one hand, CIs significantly improve audition and provide important benefits for speech perception (e.g., Blamey et al., 2001), speech and language production (Horga &
Liker, 2006), linguistic development (Connor, 2006), and speech intelligibility
(Descourtiex et al., 1999; Vieu et al., 1998). On the other hand, data collected
in the past 25 years has demonstrated that CS enhances speech perception
through the visual modality (Nicholls & Ling, 1982). As Hage and Leybaert
(2006) note, the introduction of CIs have changed the situation of children
who are profoundly deaf and raised with CS.
Descourtieux (2003) carried out one of the few published studies with
persons using both CIs and CS. The sample consisted of 55 children from 3 to
16 years old, including 42 with a CI. Open-set word perception was assessed
in three modalities: auditory alone (A); auditory and speechreading (A+SR);
and CS without any sound. Performance under A+SR and CS conditions was
higher than 80% correct. The CS condition showed a slight advantage, which
the authors attributed to a certain amount of phonological information that is
perceived more precisely through the CS modality than through A+SR. Even
in younger children (3 to 4 years old) who received implants before the age
of 3, CS seems to be an efficient tool for perceiving spoken language. Whatever the benefits of CI, early and intensive use of CS helps develop phonology. The combined use of CI and CS shows promise for the acquisition of
linguistic skills.
In our study, a CS system was introduced into a structured intervention
41
program called Modelo Oral Complementado (MOC; the English translation
for MOC is Cued-Oral Model). MOC is a program for children who are
profoundly deaf and whose families have used CS consistently and systematically with them, beginning before they were 3 years old. The primary goal
of MOC is to achieve high levels of reading ability through the development
of high linguistic competence. The MOC program works in three domains: (1)
oral language acquisition; (2) cognitive training program; and (3) output program (speech and writing).
The MOC has additional requirements: (1) children must start the program
before they are 2 years old; (2) children must be equipped with listening
devices (preferably CIs) as soon as possible and must use them in a systematic
way; and (3) parents must be taught how to use CS with their children at
home and must use it consistently and systematically. The parents train on a
computer-assisted instruction system (available at www.uma.es/moc). They
are supported through the training by a specialist so they can become proficient CS users as quickly as possible.
Research Questions
In our study, we used an emotional inferential comprehension task to
measure whether CS combined with CIs improves the reading ability of
students who are deaf or hard of hearing. Our starting point was that linguistic competence is a necessary requirement to become a skilled reader and
we remain convinced that CS and CIs together can provide students with a
sufficient level of linguistic competence. Students will have to achieve the
linguistic competence appropriate to their age (according to CELF[Clinical
Evaluation of Language Fundamentals]-3 normative data), but linguistic
competence alone does not mean high reading ability. In fact, many hearing
students with high linguistic competence do not have high reading proficiency (Perfetti, Landi, & Oakhill, 2005). To rule out specific problems with
reading, we used a standardized reading test (the Spanish PROLEC-SE test)
to determine whether the students in our study had reached age standards in
reading.
We designed an experimental task to assess the students’ ability to make
and use emotional inferences. The goal was to learn whether students who
have a hearing loss could activate interpersonal schemas with an emotional
content while they read the text we supplied. This is a high-level task—it
involves very complex reading skills and makes strong pragmatic and cognitive demands. To complete the task, the reader must activate interpersonal
schemas, assume mental states in their interlocutors, and make emotional
inferences. The results show whether the students who are deaf or hard of
hearing in our sample were able to successfully cope with the inferential
nature of the task and the emotional content of these kinds of inferences.
According to current theories on mental models in text comprehension,
42
building inferences is the hardest part of comprehending narrative texts (Van
den Broek, Virtud, Gaddy, Tzeng, & Sung, 2002). There is no way to make
progress in text comprehension without making some inferences, which demonstrates the ability to build and analyze active information from textual
stimuli. It is assumed that any text comprehension process involves a strong
inferential component, either at the local level (syntactic) or at the global or
situational level (discursive), and that the two levels are interconnected. Because of the linear character of the reading process, the syntactic level is a
necessary step in text comprehension. The reader must identify, store, and
connect information that he or she can use to track more global ideas. This
information occurs throughout the text; the reader must put it together to
achieve global comprehension of the text. Picking up the main ideas is usually
a primary goal in text comprehension.
The special nature of emotional inferences in narrative text means that a
person can integrate different pieces of information distributed throughout
the text because emotions are linked to the protagonists of the story. Emotions
can contribute to global text coherence (De Vega, León, & Díaz, 1996). Emotional representations can help clarify ambiguities and incongruencies in the
text resulting from the introduction of new characters, changes in time and
place, causal discontinuities, and so on.
We studied four children with hearing loss who had been raised in the
MOC program using cochlear implants (CI) as listening devices and cued
speech (CS) as a communication system (MOC group). The children were
asked to read two versions of the same text. The first version was congruent
with an inferred emotional state; the second version was incongruent with
this state. According to the literature (e.g., see De Vega et al., 1996), good
readers take longer to read sentences that are incongruent with their previous
inferences about the main character’s emotional state than they take to read
sentences that are congruent with this state. These time differences are commonly accepted as a proof of reading comprehension. Good readers exhibit
time differences, indicating that they detect incongruencies, and poor readers
do not exhibit time differences, indicating that they do not detect incongruencies. This experimental technique is widely used in research on text comprehension (McKoon & Ratcliff, 1992; Rapp & Gerrig, 2002, 2006).
Method
Participants
Four children with a hearing loss and educated with MOC took part in this
experiment (MOC group). The inclusion criteria for the MOC group stated
that participants should be older than 12 years, should have followed the
MOC program completely, and should be CI users. Table 1 shows the characteristics of the participants. The children suffered from neurosensorial bilateral, prelingual, profound deafness, according to the Bureau International
43
Table 1. MOC Group Characteristics
Age at
Chronol. Hearing
Cochlear
Hearing
Hearing Loss
Start of
Participant
Age
Loss
Implantation Loss with CI Diagnosis Rehabilitation
ECA
DMF
PHL
DOM
13.10
13.4
12
12
>110 dB
>110 dB
110 dB
105 dB
CI-3
CI-7
CI-3.3
CI-3.4
40
35
35
30
dB
dB
dB
dB
7
13
8
12
months
months
months
months
8
16
10
13
months
months
months
months
d’Audio Phonologie Audiometric Classification of Hearing Impairments
(BIAP; see details at www.biap.org/biapanglais.html). Mean hearing loss in
the better ear was equal to or greater than 100 dB at 500, 1000, 2000, and 4000
Hz. There were no associated impairments.
A similar chronological age group of 30 participants with typical hearing
(CA group) was formed for comparison purposes. The MOC and CA groups
did not differ in chronological age (Z = 1.37, p = 0.17).
Another control group was formed that matched the reading age of the
MOC group (RA group). This group consisted of 28 hearing participants with
raw scores on a reading task similar to those obtained by the MOC group
(raw score range 12–18). No differences in reading level (measured with the
PROLEC-SE reading test raw score in text comprehension) were observed
between the RA and MOC groups (Z = 0.43, p = 0.63). The MOC participants
were slightly younger than their reading-age-matched hearing peers (Z =
2.56, p = 0.01).
Materials and Design
The PROLEC-SE (Ramos & Cuetos, 1999) reading test was administered to
all participants to compare the MOC and RA group. The PROLEC-SE battery
is a standardized test used widely in Spain to evaluate reading skills in
children 11–16 years old. The correlation is high between the score on the text
comprehension task and teachers’ subjective ratings. In this task, participants
are asked to read 2 short stories then answer 10 questions on each story
without referring to the text. Answers are coded as correct or incorrect, with
20 being the maximum score.
The linguistic skills of participants with a hearing loss were evaluated and
compared with those of participants with typical hearing using the Spanish
version of the Clinical Evaluation of Language Fundamentals (CELF-3) (Semel, Wiig, & Secord, 1997), which assesses language difficulties. It was administered to control for the possible role of linguistic competence in the
narrative comprehension task of participants who are deaf or hard of hearing.
The experimental task involved the self-paced reading of emotional narratives describing situations familiar to elementary school students. They were
44
adapted from De Vega and colleagues (1996) and were designed to require
the processing of global inferences about the main character’s emotional situation. This information was not explicit, so the correct judgment about emotional states in the narrative involved making inferences. The inferences were
global (rather than local) because they were connected to the main character
throughout the story. We used 42 stories (2 practice stories, 25 emotional
narratives, and 15 filler stories) in the experiment. The stories had one critical
sentence in the middle (11 stories) or at the end (14 stories). We constructed
two versions of each story. In one version, the critical sentence was congruent
with the story (i.e., in a context of uncertainty, “El se sintió inseguro” [“He felt
unsafe”]). In the other, the sentence was incongruent (in the same context of
uncertainty, “El se sintió seguro” [“He felt safe”]). Congruent and incongruent
segments did not differ in the number of letters (Z = 1.4, p = 0.14) or in word
frequency (Z = 0.3, p = 0.7).
We constructed and administered two sets of emotional narratives. The
first set mixed middle-end and congruent-incongruent narratives; the second
set was constructed with the remaining conditions, so that all the conditions
were evaluated in the two sets. The participants therefore read 25 congruent
narratives, 25 incongruent narratives, and 30 filler stories.
In addition to the group variable (MOC, CA, RA), the independent variables were the congruency of the stories (congruent versus incongruent) and
the position of the critical sentence in the text (middle versus end). The
dependent variable was the time it took to read the critical sentence.
Procedure
We administered PROLEC-SE and CELF-3 tests individually to participants
following the test norms. We provided instructions orally with CS support for
the participants who were deaf or hard of hearing. In the experimental task
with the emotional narratives, participants were seated in front of a 14-inch
monitor at a computer equipped with the Experimental Run Time System
(ERTS) (Beringer, 1999). This software controlled the presentation and recorded reading time in milliseconds (ms). The experiment consisted of a
self-paced reading task using a nonaccumulative moving window. The task
began with the instructions presented on three screens. Participants had to
press the space bar to read the next segment. Two filler stories were used as
practice texts. When the participant pressed the space bar (or after 7 seconds
had elapsed), the next segment appeared. The stories were divided into segments that usually corresponded to full sentences. Stories ranged in length
from 13 to 20 segments and segments were never longer than 10 words. In
half of the stories, when the final segment disappeared, a question appeared
on the screen along with two possible answers. Participants had to press the
left or right shift key to select their answer (the answers appeared on the left
and right sides of the screen). The question was included to force participants
45
to read for comprehension; it was not related to the emotional state of the
story characters. The two versions of each story were presented in different
sets that were applied one after the other, with some minutes between to
allow participants to rest. Text order was randomized within each set. The
entire experiment lasted about 50 minutes.
Results
In the PROLEC-SE text comprehension task, the MOC group scored between the 86th and 97th percentiles (M = 90.7, SD = 4.57) (Table 2),
showing higher reading skills than those usually found in persons who are
deaf or hard of hearing. Moreover, according to the normative data provided
in the test, the MOC group scored higher than most of the CA group (as
percentiles were used, the [hearing] reference normative sample has a mean
of 50). Statistical comparison of the MOC group with the CA group (see Table
2) showed that participants with a hearing loss had better raw scores (Z =
1.97, one-tailed p = 0.037). These data confirm the efficacy of the MOC program in developing reading skills.
We converted the participants’ raw CELF-3 scores into percentiles according to their chronological age. Scores ranged between the 67th and 90th
percentiles, with a mean of 74 (SD = 13.7) (Table 2). This suggests that the
MOC group had higher levels of linguistic competence than most of the CA
group (at least as indicated by the CELF-3 reference group). Thus, the participants who are deaf or hard of hearing not only showed normal linguistic
development, but had higher scores than the mean of students with typical
hearing.
In our experimental task, the dependent variable was reading time in the
critical segment. Values less than 500 ms or greater than 6,000 ms were excluded from the analysis, which affected less than 3.5% of the data. Because
of the small size of the MOC group, we used nonparametric statistics and
performed two different types of analysis. In the first block of analyses, we
used individual (case study) analysis on the data from the participants who
are deaf or hard of hearing to clarify the effect of text congruency on their
reading times. That is, we determined whether they showed differences in
reading times when they read sentences that were incongruent or congruent
with the mental model generated by the text. In the second block, we conducted group analyses that included the participants with typical hearing to
compare the congruency effect in the MOC group with the same effect in the
CA and RA groups. In both analyses, we took into consideration the position
of the critical sentence in the text.
Case Analysis
Through nonparametric analyses using the Wilcoxon test, we studied the
differences between congruent and incongruent reading times, taking into
46
47
13.10
13.4
12
12
ECA
DMF
PHL
DOM
19
17
13
14
RT
97
90
86
90
RT-P
119
108
105
103
CELF3
90
70
65
60
CELF3-P
3036
1803
4360
2617
Incongruent
Middle
2250
1537
2935
1963
Congruent
Middle
3227
1763
3983
2304
Incongruent
Final
1879
1218
2494
1608
Congruent
Final
RT = reading test raw score; RT-P = reading test percentile; CELF3 = CELF-3 raw score; CELF3-P = CELF-3 percentile
Age
Participant
3143
1780
4127
2442
Incongruent
Total
2042
1356
2662
1764
Congruent
Total
Table 2. Critical Segment Reading Times (totals, middle, and final position) in Congruent and Incongruent Texts. Note: The
pairs that differ significantly according to nonparametric comparison of means analyses are in bold (Wilcoxon test, p < 0.05).
account the position of the critical segment (middle or end). The reading
times of the MOC group in the critical segment are shown in Table 2 (significant differences in bold). These analyses showed faster reading times in
congruent segments in 3 of the 4 participants who had a hearing loss when
data from middle and end text positions were combined, suggesting that
these participants could detect the incongruence in the texts. This difference
was maintained in 2 participants when the position was analyzed (see participants ECA and PHL). The significant difference found in the overall analysis (see participant DOM) dissipated when position was taken into account,
although there was a clear trend in both positions favoring congruent over
incongruent texts, especially in the end position (one-tailed test p = .07).
Finally, although in both cases participant DMF showed faster reading times
in congruent texts, this trend was not statistically significant (p > 0.05).
Group Analysis
We analyzed the MOC group in relation to the two hearing groups (CA and
RA groups). According to our hypothesis, and taking into account the
PROLEC-SE test reading scores, we expected a similar data pattern from the
MOC and RA groups (i.e., significant differences between reading times in
congruent versus incongruent sentences). Differences between the CA and
MOC groups would depend on differences in reading level.
Table 3 shows mean reading times in the critical segment for the MOC
group and the two control groups, taking into account segment position and
congruency. We carried out nonparametric analyses (Wilcoxon tests) in the
MOC group regarding segment position and congruency. As expected, the
MOC group showed significant effects of congruency in the middle position
(Z = 1.82; one-tailed test p = 0.034); in the end position (Z = 1.82; one-tailed
test p = 0.034); and when all stories were considered together (Z = 1.82;
one-tailed test p = 0.034). These analyses indicated that MOC participants as
a group read the congruent stories faster than the incongruent ones; that is,
they were able to detect the inconsistency between the incongruent sentences
and the mental model created from the texts, leading to higher reading times
with the incongruent stories.
In the CA group, significant differences were found between the congruent
and incongruent texts in the end position (Z = 2.87, p = 0.004) and when
middle and end position data were combined (Z = 2.77, p = 0.006). However,
the differences were not significant when segments in the middle position
were taken into account (Z = 0.73, p = 0.46). This pattern contrasts with that
found in the MOC group, where differences between the congruent and
incongruent texts always appeared, regardless of critical segment position.
We compared the MOC group with the CA group to explore reading time
differences and—more importantly—the size of the congruency effect. We
used Mann-Whitney nonparametric tests to compare the size of the congruency effect; the comparison showed that the MOC participants were more
48
49
12.7
(0.8)
13.2
(1.5)
14.3
(1.5)
MOC
N=4
CA
N = 30
RA
N = 28
15.75
(2.7)
12
(3.7)
15
(1.7)
Reading Test
Raw Score
2152
(600)
2772
(508)
2450
(472)
Congruent
Middle
2977
(1108)
2827
(592)
2609
(648)
Incongruent
Middle
1783
(512)
2122
(440)
1927
(487)
Congruent
Final
2819
(983)
2328
(458)
2227
(571)
Incongruent
Final
1943
(546)
2400
(432)
2153
(443)
Congruent
Total
2885
(1024)
2546
(467)
2394
(561)
Incongruent
Total
MOC = deaf with CI and educated with cued speech; CA = hearing peers matched in chronological age; RA = hearing peers matched in reading age.
Age (years)
Group
Table 3. Mean Reading Times (in ms) in the Critical Segment in the Three Experimental Groups in Congruent and Incongruent
Texts Regarding Position (SD in parentheses). Note: The pairs that differ significantly according to congruency, as within group
factor, using nonparametric comparison of means analyses are in bold (Wilcoxon test, one-tailed p < 0.05).
affected by this factor than the CA participants in the middle position (Z =
2.56, p = 0.01); in the end position (Z = 2.83, p = 0.005); and when the data
were combined (Z = 2.94, p = 0.001). The comparison also showed that MOC
participants read the congruent segments numerically faster and the incongruent segments more slowly than the CA group, but the differences were not
statistically significant (all ps > 0.05).
When we analyzed the RA group, we found that differences between the
congruent and incongruent texts were marginally significant in the middle
position (Z = 1.65, one-tailed test p = 0.05) and fully significant in both the end
position (Z = 3.28, p = 0.001) and when all data were analyzed together (Z =
3.8; p < 0.001). This pattern is very similar to that found in the MOC group.
When we compared the size of the congruency effect between the two groups,
we found that the MOC participants were more affected than their RA peers
by the congruency factor, regardless of the position of the critical segment
(middle position: Z = 2.45, p = 0.014; end position: Z = 2.50, p = 0.012; total:
Z = 2.67, p = 0.007). We found the same result when we compared the MOC
group with the CA group. With regard to the times taken to read the critical
segments (both incongruent and congruent), our analyses showed that although the MOC participants read the congruent segments numerically faster
and the incongruent segments more slowly than the RA group, the differences were not significant.
Discussion
In this study, we analyzed the reading comprehension of MOC participants
using texts with emotional inferences. This task is considered an advancedlevel reading task.
According to the CELF-3 test results, the MOC subjects demonstrated a
reasonable level of linguistic competence (above the 50th percentile), indicating a command of spoken language. These results have important implications for reading comprehension. As stated earlier, good reading skills are
impossible without linguistic competence, whatever the mode of communication. Children who do not possess any language to serve as a basis for
written symbols will never learn to read. As the CELF-3 test results indicate,
the MOC participants had a certain level of linguistic competence; in this case,
spoken language.
The results of the PROLEC-SE text comprehension task confirmed a high
level of reading skills. We evaluated this capacity independently because
linguistic competence by itself, although necessary, is no guarantee of fully
developed reading skills. All participants in the MOC group scored above the
85th percentile, indicating that they were skilled readers for their age, not
only compared with other persons who are deaf or hard of hearing but also
with their peers with typical hearing.
The results of our study demonstrate that the skill levels of the MOC group
50
in both reading and linguistic competence favorably position them for success
in a reading comprehension task using texts with emotional inferences. When
we examined the results of this task, we found significant differences in the
reading time for the target sentences used as a dependent variable (i.e., between congruent and incongruent sentences). This led us to conclude that the
MOC participants, as a group, could detect the incongruencies in the text. We
observed the same effect regardless of the position of the critical sentence. All
participants exhibited a similar pattern of reaction: a longer response time for
the critical incongruent sentences. This difference was significant in all the
participants, except participant DMR.
We found some differences between the MOC group and the CA group.
The CA group did not show a consistency effect when the critical segment
was in the middle, although the effect appeared when the segment was at the
end. It has been said that some less skilled readers expect information about
the protagonist’s story to be updated at the end of the text. If this is true, the
lack of consistency with regard to the middle position would indicate that the
CA group has a lower reading ability. This argument is supported by the fact
that the MOC group had better scores in the PROLEC-SE test.
When we compared the MOC group with the RA group, the two groups
showed a similar pattern of reaction: consistency effects in the middle position (although marginal) and at the end of the text. On the basis of these
results, we can say that the reading skills of the MOC group in this sample are
similar to those of the RA group when they have to make emotional inferences. Because the MOC students have achieved good reading skills and
linguistic command, they do not have a hard time establishing and updating
information on the emotional state of the protagonist while they are reading.
An important point is that, compared with both the CA and RA groups, the
MOC group showed a bigger discrepancy effect between the congruent and
incongruent sentences. This indicates that the MOC children have a greater
ability to detect anomalies in text. This suggests that (1) the MOC children
have good comprehension of the text, because that is the only way to detect
incongruencies, and (2) they have a strong bottom-up strategy for detecting
mistakes that allows them to detect incongruencies (which is highly positive),
but may reflect comprehension processes that are less automated. In support
of the latter conclusion, the results indicate that reading time differences in
incongruent sentences are always longer for people who have a hearing loss
than for people with typical hearing.
We should also point out that the smaller size of the congruence effect in
the children with typical hearing is not necessarily a direct indicator of lower
reading ability. It can also indicate a greater tolerance for mistakes, which
allows them to read more fluently. Good readers rely on the context to resolve
ambiguities, so it is possible that the children with typical hearing detect the
incongruence but do not consider it sufficiently relevant to slow down their
reading activity (De Vega et al., 1996). In natural conditions, the final aim of
51
a reading task is to extract the global meaning of the text, not to detect errors.
In fact, to a certain extent, we can attribute the detection of incongruencies to
the MOC method itself, which explicitly uses these strategies to detect errors.
Overall, our findings indicate that the children in the MOC group coped
successfully with a complex emotional inference task. Their results were not
inferior to those of the CA or RA group. According to the research cited
earlier in this paper, this performance can be explained by the following: (1)
the communicative modality chosen (cued speech); (2) the use of a cochlear
implant as a listening device; and (3) a systematic and structured intervention
program (MOC) that allows students to take advantage of CS and CIs.
1. The Communicative Modality. The oral communicative modality plus
CS has demonstrated efficacy in the development of linguistic competence.
The CS modality satisfies all four of Musselman’s parameters for analyzing
communication systems in relation to reading acquisition (Musselman, 2000,
p. 25). Of these 4 parameters, 2 (codification and structural isomorphism)
highlight the relationship between interpersonal communication systems and
the written text, and the other 2 (accessibility and processability) point to the
extent to which the communication systems adapt to the capacities of children
who are deaf or hard of hearing.
The CS system has some advantages related to codification and structural
isomorphism. Regarding the former, CS is a completely transparent system
for the written code. Its cueing system enables us to codify the same segments
for speech that later will be relevant in reading. This property helps persons
who are deaf or hard of hearing avoid the problems inherent in transposing
sign or manual systems. CS involves no code problems, because it codifies the
same spelling components as oral language and practically establishes the
same correspondences. As far as structural isomorphism, the correspondence
with oral language is complete because CS is not a language in itself, but a
codification system for oral language. Thus, the structures and units of CS are
exactly the same as the oral language the child with a hearing loss uses.
In the case of the other two parameters—accessibility and processability—
our study indicates that they are completely suitable to the processing capacities of persons who are deaf or hard of hearing. According these two
parameters, CS fulfills its role as a communicative modality and a modality of
access to information. CS does not pose a problem for accessibility because
children who are deaf or hard of hearing learn it spontaneously when adults
consistently communicate with them using CS, regardless of their age. These
children access CS the same way children with typical hearing access oral
language (Leybaert & Charlier, 1996; Torres et al., 2006).
2. The Use of CIs. Cochlear implants play a key role in explaining our
results. The use of CIs can be considered the ideal complement to CS, and vice
versa. The main aim of CS is to make oral language fully visible, different, and
complete, thus enabling language perception. The direct consequence of fulfilling this aim is that it makes the acquisition of oral language easier. CIs
52
have the same aim, although they use auditory rather than visual perception.
If oral information is accessible through an auditory channel (CI), a visual
channel (CS), or both, the acquisition of oral language will be facilitated.
Depending on the starting time, the number of years exposed to the system
and the amount of input, CS (in theory, at least) solves the problem of language perception and allows persons who are deaf or hard of hearing to
access oral language. In the same way, CIs (which also depend on starting
time, duration of use, and correct use) efficiently contribute to acquiring oral
language. The clear superiority of CIs over other conventional listening devices has been demonstrated. Although in some circumstances it is possible to
access a great part of the auditory information in the environment using other
devices, CIs provide more and better auditory information than any other
device (see Geers, 2006, for a review).
Previously, we discussed the proven advantages of CS for spoken language
competence and reading ability. In this study, we have focused on the CI-CS
combination. We attribute these results to the joint long-term working effect
of a specific listening device (CI) and a communication system based on the
spoken language (CS).
3. A Systematic and Structured Intervention Framework. Most children
with hearing loss are born to parents with typical hearing who do not have
intense and specific training in any communicative modality. Parents should
master one of these modalities so they can interact with their child. As we
noted earlier, it is important to ensure that when children who are deaf or
hard of hearing start school, their linguistic competence matches their chronological age. If it does not, they will have to try to learn to read without
language competence, which will hinder the potential of their learned communicative modality (whatever it might be) as an instrument for interpersonal and instructional communication.
The participants in our study avoided that situation. They completed the
MOC program (1–12 years); received a CI early in life and used it properly;
were exposed to CS at home between the ages of 1 and 2 years; and their
parents were deeply involved in the project. Last but not least, the MOC
approach is a structured program of cognitive and language abilities training,
with special emphasis on low- and high-level reading processes.
Conclusion
The research data presented here are based on a small sample size, but they
are in line with the work of Spencer (2004), who suggests that, in addition to
CIs, other factors must be considered for increased reading comprehension,
such as the pre-implant auditory experience, the communication system
used, and how strongly the family is engaged. Following Spencer’s advice,
we strongly controlled for these variables in the MOC group.
Various studies have compared the age at which the recipient obtained the
53
cochlear implant and the different communication systems the CI user utilizes. Receiving a CI early has a positive impact on oral language acquisition
and use as well as on oral communication systems when compared with other
communication systems. Despite the clear advantages of receiving a CI early
in life, the oral linguistic development of people who are deaf or hard of
hearing is not entirely the same as that of their peers with typical hearing. The
data suggest the advantage of maintaining oral intervention models and systems, like CS, in combination with the use of CIs to accurately represent the
formal aspects of oral language present in written text.
Acknowledgments
This research was supported by a grant from the Spanish Ministry of Science and Technology (DGICYT Ref. BSO2003-08002/PSCE). We wish to express our gratitude to Manuel de Vega, Inmaculada León, and Jose-Miguel
Díaz for their assistance with the experimental texts, and also to Rafael Santana and Mauricio Iza for their comments and assistance with manuscript
preparation. We would also like to thank the deaf and hearing students who
took part in this study, and the staff of the school where the research was
carried out: Instituto Belén (Málaga). Without their help, the research would
not have been possible.
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57
The Conditioned Assessment
of Speech Production (CASP):
A Tool for Evaluating
Auditory-Guided Speech
Development in Young
Children with Hearing Loss
David J. Ertmer, Ph.D., and Carol Stoel-Gammon, Ph.D.
Prelinguistic vocal development is “the process by which infants and toddlers
produce increasingly more complex, phonetically diverse, and speech-like utterances
before they say words on a regular basis” (Ertmer, 2005, p. 85). Research has shown
that children with bilateral, moderate-to-profound hearing loss experience delays and
deficits in vocal development compared with children who are developing typically.
However, most of these investigations were completed before the widespread adoption
of universal newborn hearing screening. More recent studies have shown that providing hearing aids or cochlear implants to infants and toddlers can lead to noticeable
advancements in vocal development soon after sensory aid fitting. Given the increasing number of infants identified with hearing loss, there is a pressing need for a
reliable and practical way to measure these auditory-based speech gains. This article
describes the development and field testing of the Conditioned Assessment of Speech
Production (CASP), a time-efficient tool for assessing children’s progress in vocal
development. The CASP is based on 3 premises: (1) increased auditory access to
conversational speech models and auditory feedback through sensory aids will lead to
noticeable advancements in vocal development; (2) sensory aid benefit is demonstrated
when children imitate progressively more complex, phonetically varied, and speech-like
David J. Ertmer, Ph.D., is an associate professor in the department of speech, language, and
hearing sciences at Purdue University. Carol Stoel-Gammon, Ph.D., is a professor in the
department of speech and hearing sciences at the University of Washington. Correspondence
regarding this article should be addressed to David J. Ertmer, Ph.D., at (765) 496-2249 or
[email protected].
The Conditioned Assessment of Speech Production (CASP)
59
vocalizations; and (3) toddlers can be conditioned to imitate developmentally appropriate speech stimuli modeled by a familiar person during a game-like activity. Field
testing was conducted with 13 children who had prelingual onset of hearing loss and
15 children who were developing typically. The study explored 2 main questions: (1)
At what ages will children actively participate in CASP? (2) Do CASP scores
increase with age, sensory aid experience, and increased aided hearing levels? Field
testing revealed that children as young as 12 months imitated CASP stimuli and that
CASP scores increased with age and sensory aid experience. We did not detect a
relationship with aided hearing levels. Implications for assessment and intervention
are discussed.
Introduction
The widespread adoption of universal newborn hearing screening (UNHS)
has made it possible to identify infants who have moderate to profound
hearing loss within the first month of life. Infants who are identified with
hearing loss commonly receive hearing aids and begin to receive familycentered services shortly thereafter. The benefits of such early intervention
have been clearly confirmed in studies of language development in preschool
and school-aged children by Yoshinaga-Itano and colleagues (1998) and by
Moeller (2000). Along with these benefits, however, new challenges have
arisen for professionals who provide aural habilitation for infants and toddlers. In particular, there is a pressing need for objective methods of evaluating auditory and speech development during the initial months of sensory
aid use. This article describes the rationale, development, administration, and
field-testing of the Conditioned Assessment of Speech Production (CASP).
The CASP is a criterion-referenced tool that examines the effects of sensory
aid use on prelinguistic speech development by eliciting increasingly complex and phonetically diverse utterances via a game-like activity involving
parents and early interventionists (EIs).
Prelinguistic Vocal Development
Prelinguistic vocal development (hereafter referred to as “vocal development”) is “the process by which infants and toddlers produce increasingly
more complex, phonetically diverse, and speech-like utterances before they
say words on a regular basis” (Ertmer, 2005, p. 85). Researchers have characterized vocal development as a series of overlapping levels in which new
kinds of vocalization emerge and become more common (e.g., Koopman-van
Beinum & Van der Stelt, 1986; Nathani, Ertmer, & Stark, 2006; Oller, 1980;
Roug, Landberg, & Lundberg, 1989; Stark, 1980; see Vihman, 1996, for a
review). Advancements to higher levels of vocal development are considered
evidence of progress toward meaningful speech in children who are developing typically (Stoel-Gammon, 1998) and can be indicators of auditoryguided speech development for children with hearing loss as well.
60
Ertmer & Stoel-Gammon
Numerous studies have shown that young children with bilateral, moderate, or severe-to-profound hearing loss have significant deficits in vocal and
phonetic development compared with children developing typically. These
deficiencies include late onset of canonical babbling (Moeller et al. 2007a;
Oller & Eilers, 1988); restricted formant frequency ranges limiting vowel diversity (Kent, Osberger, Netsell, & Hustedde, 1987); and smaller consonant,
vowel, and syllable shape inventories than children with typical hearing
(Moeller et al. 2007a; Stoel-Gammon, 1998). Delays in the onset of canonical
babbling and more complex syllable shapes have also been found in children
with moderate hearing loss (Nathani, Oller, & Neal, 2007). Prelinguistic
speech deficits have been associated with delays in phonological development and early word production (Ertmer & Stark, 1995; Moeller et al. 2007b).
Recently, however, it has been shown that infants and toddlers who receive
auditory access to conversational-intensity speech via a cochlear implant (CI)
and who have no additional physical or learning difficulties can make relatively rapid advancements in vocal development (e.g., McCaffrey, Davis,
MacNeilage, & von Hapsburg, 1999; Ertmer & Mellon, 2001; Ertmer, Young,
& Nathani, 2007). Thus, progress in vocal development can be viewed as a
positive indicator of sensory aid benefit. The CASP was designed to be a
practical way of monitoring such progress.
Development of CASP
Two previously published investigations served as the basis for the development of the CASP. The first examined typically developing infants and
toddlers, and the second examined children who received CIs before their
third birthday. Nathani and colleagues (2006) used the Stark Assessment of
Early Vocal Development-Revised (SAEVD-R) to classify the prelinguistic
utterances produced by typically developing infants and toddlers during play
sessions with their mothers. The SAEVD-R is based on research showing that
simple, non-speech-like vocalizations (e.g., grunts, clicks, squeals, isolated
vowels) are gradually replaced by more complex and speech-like productions
(e.g., CV [consonant-vowel] syllables, strings of CV syllables [babbling], and
CVC syllables; see Oller, 2000, and Vihman, 1996, for reviews). There are five
SAEVD-R levels:
Level 1. Reflexive sounds (e.g., crying/discomfort, cooing)
Level 2. Control of phonation (e.g., fully resonant nuclei, chuckles, lip
smacks)
Level 3. Expansion (e.g., vowels/vocants, vowel glides, squeals)
Level 4. Basic canonical syllables (e.g., CV syllables, babbling, CVCV syllables)
Level 5. Advanced forms (e.g., CVC syllables, VCV syllables, diphthongs)
61
For a full description of the SAEVD-R categories and operational definitions,
see Nathani et al. (2006).
The results of this cross-sectional study showed that (1) the proportions of
Level 1 and 2 vocalizations gradually decreased from moderate to very low
amounts over the first 20 months of life; (2) Level 3 vocalizations dominated
between 3 and 15 months but decreased substantially at 16–20 months; and
(3) more complex, adult-like vocalizations from Level 4 and Level 5 emerged
and increased in sequence, and eventually accounted for the majority of
vocalizations in the oldest age group (16–20 months). Nathani and colleagues
(2006) concluded that the SAEVD-R was a sensitive measure of age-related
changes in speech production in infants and toddlers who were developing
typically.
In the second study, Ertmer and colleagues (2007) used a prospective longitudinal research design to examine vocal development in seven children
who received CIs before their third birthday. Thirty-minute mother-child
play sessions were video- and audiotaped twice before CI activation and each
month thereafter until the process of vocal development was complete.
The 2007 Ertmer and colleagues study produced 4 main findings:
1. Six of the 7 children advanced to higher SAEVD-R levels after CI activation. The child who did not make progress failed to establish the
advanced forms level and was later identified as having learning difficulties in addition to hearing loss.
2. Six of the 7 children followed the sequence predicted by the SAEVD-R.
The youngest child (who received the implant at 10 months) established
advanced forms (Level 5) before basic canonical syllables (Level 4).
3. Milestones such as the establishment of basic canonical syllables and
advanced forms were usually achieved with fewer months of auditory
access to conversational-intensity speech than observed in children developing typically.
4. Children who received implants at younger ages completed the process
of vocal development at younger chronological ages than those who
received implants at comparatively older ages.
Taken together, these studies showed that prelinguistic vocal development
is predictable in children with typical hearing and that improved access to
conversational speech models and auditory feedback via sensory aids can
lead to observable advancements in vocal development for children with a
hearing loss.
Rationale for CASP
The CASP was developed to provide EIs with a time-efficient way to monitor vocal development. It is based on 3 premises: (1) increased auditory access
62
to conversational speech models and auditory feedback through sensory aids
will lead to noticeable advancements in vocal development; (2) sensory aid
benefit is demonstrated when children imitate progressively more complex,
phonetically varied, and speech-like vocalizations; and (3) toddlers can be
conditioned to imitate developmentally appropriate speech stimuli modeled
by a familiar person during a game-like activity.
CASP Stimuli
In addition to confirming the positive effects of CI use on vocal development, the 2007 study by Ertmer and colleagues revealed that improved hearing sensitivity led to increased productions from SAEVD-R Levels 4 and 5,
more so than advancements across Levels 1, 2, and 3. This finding agrees with
those of Stark (1983) and Stoel-Gammon and Otomo (1986), who showed that
many vocalization types produced during the first 6 months of life are observed in children who are deaf as well as those with normal hearing. Using
this information, a 3-level classification system was developed that included
precanonical vocalizations (SAEVD-R Levels 1–3 combined), basic canonical
syllables (SAEVD-R Level 4), and advanced forms (SAEVD-R Level 5). We
used this simplified system to select 3 levels of speech stimuli for CASP (for
a similar 3-level system, see Stoel-Gammon’s mean babbling level [1989]).
Stimuli from each of these levels are represented by symbols from the International Phonetic Alphabet (IPA), so EIs must be familiar with broad phonetic transcription to administer CASP.
Precanonical vocalizations lack the phonetic content (i.e., consonants and
vowels in combination) and the rapid, adult-like timing of true syllables (see
Oller, 2000, for a discussion). Three different vowels are used as stimuli at this
level of the CASP, because increased vowel diversity has been found to be an
early indicator of speech development after receiving a cochlear implant (Ertmer, 2001; Ertmer, Kirk, Todd, Riley, & Osberger, 1998). Central (//), highfront (/i/) and low-front (/æ/) vowels were chosen because they have very
limited speechreading cues (i.e., no lip-rounding), causing children to rely
mainly on auditory information for imitation.
Stimuli from the next CASP level, basic canonical syllables, consist of consonant and vowel (CV) syllables with adult-like timing (Oller & Lynch, 1992).
Two kinds of canonical syllables are presented: 3 CV syllables with highly
visible consonants (i.e., [bɑ], [mɑ] and [wɑ]) and 2 CV syllables containing
consonants with minimal speechreading cues (i.e., [kɑ] and [sɑ]). The former
are used to assess syllables with consonants that typically emerge early in life.
The latter CV syllables are expected to be produced after extended sensory
aid use because of their non-visable places of production and relatively later
emergence in typically developing children (Sander, 1972).
The third set of stimuli, advanced forms, includes a consonant plus a diphthongized vowel syllable (i.e., [naI]) and a CVC syllable (i.e., [tk]). These
63
Figure 1. Fisher Price Classical Stacker Toy
vocalizations assess the child’s ability to produce the rapid formant transitions associated with diphthongs and closed syllables. Both of these types of
syllables are among the later-emerging kinds of vocalizations observed in
typically developing toddlers (Nathani et al., 2006) and young CI recipients
(Ertmer et al., 2007), and are rarely observed in young children who are deaf
(Moeller et al., 2007b; Stoel-Gammon & Otomo, 1986). Speechreading cues are
minimal in these stimuli, so imitation relies mainly on auditory perception
ability.
Procedures for Administering the CASP
In addition to taking advantage of a young child’s natural inclination to
imitate, 3 techniques are used to optimize child participation in the CASP.
First, the child’s parent and a familiar clinician serve as role models for
imitation. The clinician models each stimulus item to the parent as the
child observes. The parent listens to the model, imitates it, and receives a
reinforcer (i.e., a star from a Classical Stacker toy, Figure 1). Adult roleplaying is intended to help the child understand the task and to increase
motivation for participation. Second, after role-play, the parent turns to
the child and models the same item for the child to imitate. In this way,
64
the child is asked to respond to a familiar partner by performing a task
that has recently been demonstrated. Finally, the child’s imitative attempts are rewarded with a star from the stacker toy. The toy lights up
and makes a pleasant sound as each star is placed on the post; it plays a
short melody when all the stars are in place. In summary, the CASP is
a short (10-item), game-like experience for the child. Complete instructions are given in Appendix A, and a video demonstration is available at
www.agbell.org/DesktopDefault.aspx?p=The_Volta_Review.
CASP Scoring
The CASP uses a graduated scale to judge the acceptability of children’s
imitative responses. Each response is classified as an acceptable match (2
points), an approximation (1 point), or unacceptable (0 points). Criteria for
each CASP item are included on the score sheet (Appendix B).
There are 2 types of acceptable matches. Two points are assigned when
children produce utterances that contain satisfactory matches of the vowels
and/or consonants in each model (e.g., the model is [wɑ] and the child says
[wɑ]). Full credit is also given when near-neighbor vowels (i.e., those represented in similar locations on a vowel quadrilateral) are substituted for vowel
targets and/or consonants are an acceptable match in manner and place of
articulation, but not in voicing. For example, if a child says [dɑg] for the target
[tk], full credit is given because the response contains a near-neighbor vowel
and consonants with features that are correct except for voicing. Acceptable
vowels and consonants are listed on the score sheet for each item.
Imitations that contain some phonetic aspects of the model are considered
approximations and receive 1 point. For example, a child who attempts to
imitate the two-vowel model /i/ /i/ by saying /ɑ/ /ɑ/ has matched the
correct number of vowels, even though matching vowel types were not produced. Acceptable approximations for each item are included on the score
sheet.
Unacceptable responses include failure to imitate and productions that are
quite dissimilar from the model. For example, [pu] would be an unacceptable
imitation of the target [sɑ]. Nonresponses and phonetically dissimilar productions receive no points. There are at least 4 possible explanations for these
kinds of responses: (1) the stimulus was not perceived well; (2) production of
the stimulus is beyond the child’s ability; (3) the child is not inclined to
imitate; or (4) a combination of these explanations. Although it may not be
possible to know the reason for unacceptable responses, it is useful to make
notes about the children’s willingness to participate and the kinds of responses they produce for comparisons with later administrations.
65
66
MASU
AMBU
MASA
JAST
ANES
ANNU
ERLE
BRWO
RYLA
LANO
STPA
CHLA
JOSI
M
SD
Ranges
M
F
M
F
F
M
M
F
M
F
M
F
M
Gender
9
3
23
23
13
10
11
1
23
33
30
18
20
16.7
9.8
1–33
Age at Fitting
(months)
CI
HA
HA
HA
CI
HA
CI
HA
HA
HA
CI
CI
CI
Sensory
Aid
30
48
40
33
27
32
27
23
50
25
28
17
27
31.3
9.5
17–50
Average Aided
Threshold
(dB HL)
12
24
24
26
33
33
35
36
34
43
44
45
47
33.5
10.1
12–47
Age at
Test 1
(months)
2
8
2
12
8
14
13
16
16
14
10
11
17
11
4.9
2–17
Test 1
Score
Table 1. Demographic and Audiological Information and CASP scores for Children with Hearing Loss
13
15
15
14
19
19
17
19
20
19
16
16
20
17
2.4
13–20
Test 2
Score
+11
+7
+13
+2
+11
+5
+4
+3
+4
+5
+6
+5
+3
+6.1
3.5
+2–+13
Test Score
Difference
Methods
Field Testing
The purpose of CASP is to detect and monitor within-child changes in
vocal development through imitative, prelinguistic speech patterns. Benefit
from sensory aid experience can be inferred as children imitate progressively
advanced vocalizations with increasing acceptability. The effectiveness of the
assessment tool depends on the willing participation of young children. Improved hearing ability should be reflected in higher CASP scores as children
gain more sensory aid experience. It is also possible that children who have
better aided hearing sensitivity will score higher than those with lower
thresholds. The field-testing addressed two main questions: (1) At what ages
will children actively participate in CASP? (2) Do CASP scores increase with
age, sensory aid experience and aided hearing levels?
Thirteen children with bilateral hearing loss ranging from severe to profound participated in the field testing (HL group). Seven children used hearing aids (HAs) and 6 used CIs. All the children were receiving familycentered intervention or were enrolled in preschool classes at Child’s Voice,
an oral education program in Wood Dale, Illinois. The CASP was administered to these children twice: in April 2003 and 10 months later in February
2004. Table 1 shows the children’s ages at the time of testing, audiological
information, and CASP scores. The amount of sensory aid experience for each
child was based on the type of sensory aid they used during the testing. Thus,
children who used CIs were credited with sensory aid experience equivalent
to the length of time they had used their implants. CASP was also given once
to 15 children developing typical hearing (TD group) to further explore the
age range for willing participation and the relationship between CASP scores
and chronological age. All of these children were between 12 and 47 months
old; had passed sound-field testing with warble tones and tympanometry
screenings; and were reported to have no physical or learning disabilities.
Table 2 shows the ages, genders, and CASP scores for the TD group.
Interscorer Reliability and Validity
Eight graduate students with training in phonetics administered CASP.
These administrations were video- and audiotaped so that scoring reliability
could be examined later. Interscorer reliability was estimated by having a
different clinician review the recordings and rescore the first administration
of CASP for each of the children in the HL group and for two randomly
selected administrations of CASP from the TD group (37% of all administrations). Recordings for each of the children in the HL group were rescored
because it was expected that their speech would provide a rigorous sample
67
Table 2. Gender, Age, and CASP scores for Children Developing Typically
GIBE
MARS
ELBE
KRLE
AMSI
MAMA
HEJA
NISC
MARO
MCFR
ALWA
MADS
ALSA
FIBE
LEPO
M
SD
Ranges
Gender
Age at Test (months)
Test Score
F
F
F
F
F
F
M
M
M
F
F
F
M
F
M
12
16
17
18
18
17
20
27
28
35
38
39
41
44
47
27.8
11.8
12–47
DNP*
9
15
0
0
2
1
DNP*
17
19
19
16
20
20
20
12.2
8.5
0–20
*Did not participate
for assessing interscorer reliability. These reliability checks indicated that
comparable scores can be expected when the CASP is scored by different clinicians. The mean difference between the original and second sets of total
scores was 0.8 points (SD = 0.29), and the two sets of scores were highly
correlated (r = 0.98 [p (14) = <0.001]). An item-by-item comparison revealed
that 112 of 128 item-scoring decisions (i.e., 0, 1, or 2 points) were in agreement
(88%) and that scores for individual items never differed by more than 1
point.
The content validity of the CASP is considered to be high because it
samples a continuum of vocalization types that emerge with increasing age in
typically developing infants and toddlers, and with increased sensory aid
experience in children with hearing loss (Ertmer et al., 2007; Nathani et al.,
2006).
Results of Field Testing
As Table 1 shows, all children in the HL group attempted to participate in
CASP, including a child who was 12 months old. Scores from the first administration of CASP were highly correlated with chronological age (r = 0.73;
p ⱕ 0.01) and amount of sensory aid experience (r = 0.62; p ⱕ 0.02). CASP
scores were not significantly correlated with children’s aided hearing levels
(r = −0.46). Total scores from the second administration of CASP (M = 17
points) were significantly higher than those obtained 10 months earlier (mean
68
difference = 11 points; Wilcoxon Signed Ranks Test; p ⱕ 0.00]). As Table 1
shows, each child in the HL group achieved higher total scores on the second
administration of the CASP.
Although a nonlinear distribution of scores was observed, CASP scores
were also highly correlated with age in the TD group (r = 0.82; p ⱕ 0.001). As
Table 2 shows, children as young as 16 months participated in CASP. However, scores for children <28 months were more variable (range = 0–15 points)
than scores for children ⱖ28 months old (range = 16–20 points). Table 2 also
shows that 13 of 15 children attempted to imitate CASP stimuli. Thus, the
imitation task and reward system of CASP were engaging for most of the
children in the TD group. These findings indicated that CASP can be used
with children who are between 16 and 48 months old and typically developing. Although CASP scores and age were strongly correlated, considerable
variability was observed in children younger than 30 months in both groups.
Discussion
Field testing helped to resolve issues regarding the clinical usefulness of
CASP for monitoring changes in prelinguistic speech development in young
children with hearing loss. The following sections consider findings for the
two main questions addressed by the field testing, cautions for interpreting
CASP scores, allowable modifications to administration procedures, and implications for intervention planning.
Question 1: At what ages will children actively participate in the CASP?
Data from the HL group suggests that children who are as young as 12
months of age can participate in the CASP. This finding was somewhat unexpected and should be interpreted cautiously, as only one child in the HL
group was this young. A natural tendency for children with hearing loss to
imitate speech and previous experience in turn-taking during intervention
sessions might have enabled this child (identified as MASU) to participate in
the CASP. It is anticipated that many infants and some young toddlers will
resist participating, at least at first. Participation requires a readiness to imitate speech stimuli. EIs can assess children’s readiness by observing how
often they imitate vocalizations during play. For example, children who produce animal sounds (e.g., “ee” for a horse, “baa” for a sheep, or “moo” for a
cow) spontaneously may be ready to participate in the CASP. If children are
unresponsive when the CASP is first attempted, EIs can postpone administration for a later date and emphasize imitative turn-taking during intervention sessions. All of the child’s attempts to imitate CASP stimuli should be
scored, even if he or she becomes uncooperative during the test. These initial
scores will provide a baseline for comparison with later CASP scores.
69
Field testing results suggest that children who are 30 months or younger
may experience the most difficulty with CASP procedures. Some may refuse
to participate at all. In such cases, EIs can estimate vocal development by
classifying spontaneous vocalizations as precanonical, basic canonical syllables, or advanced forms during informal play activities. Operational definitions and audio examples of vocalizations from these levels can be found at
www.vocaldevelopment.com. Each of these levels can be considered established when it comprises ⱖ20% of the child’s utterances (Ertmer et al., 2007;
Oller & Eilers, 1988). Guidelines for classifying vocalizations can be found in
Ertmer (2005).
Question 2: Do CASP scores increase with age, increased sensory aid experience,
and/or increased aided hearing levels?
Field testing revealed that CASP scores increased with age in both the HL
and TD groups. In addition, children in the HL group who had used their
current sensory aids longer tended to have higher CASP scores than those
with less sensory aid experience. Scores for the TD group also revealed that
children younger than 40 months did not achieve ceiling-level performance
(20 points). Thus, the CASP stimuli appear to be a developmentally appropriate measure of vocal development for children who are younger than 40
months and for those who have fewer than 40 months of sensory aid experience. Based on the gains seen in the second administration of the CASP, it
is reasonable to expect that scores will increase during the first year of sensory
aid use. In contrast, CASP scores and children’s aided hearing levels were not
significantly associated. The lack of correlation between these measures may
be due, in part, to the similarity of aided hearing levels among the children in
the HL group. Although the range of aided pure tone averages was relatively
wide (17–50 dB HL), 9 of 13 children had average aided hearing thresholds
within a restricted range of values (23–32 dB HL). Further research with more
children and a wider range of aided hearing levels is needed to explore this
issue.
Interpreting CASP Results
Two main cautions should be kept in mind when interpreting CASP scores.
First, the CASP is intended to track progress for the same child over time.
Comparison with other sensory aid users is not possible because normative
data have not yet been collected. Likewise, expectations for the rate of increase in CASP scores are not available. Improvements in vocal development
are likely to be quite individualized, especially for children who receive sensory aids at different ages (see ASHA, 2004, for further discussion). For example, Ertmer and colleagues (2007) found that children who received
cochlear implants after age 2 made more rapid progress in vocal development
70
than those who received implants at an earlier age. Factors such as preimplant hearing levels, intelligence, aided hearing levels, and length of sensory aid use may also influence a child’s rate of vocal development. Further
study with a larger number of participants is needed to determine expected
rates of increase in CASP scores.
The second caution involves the need for a broad array of measures when
evaluating infants and toddlers during the initial period of sensory aid use.
CASP scores should be considered only part of a multifaceted evaluation that
includes audiometric results, information from parent reports, and EI observations of listening, speech, and language behaviors in natural contexts (Ertmer, 2005). Information from all these sources and evaluations in other areas
(e.g., gross and fine motor development, cognitive development, and adaptive behaviors) form the basis of an individualized and developmentally
appropriate intervention plan.
Allowable Modifications
In addition to addressing the two main research questions, field testing
provided insights into the administration of the CASP. Feedback from fieldtesters and practicing EIs revealed that some children responded more
readily to their EIs than to their parents. In these situations, we decided to
allow the parent and the EI to reverse roles. That is, the parent modeled the
target utterance for the EI, and then the EI modeled it for the child. This was
acceptable because the child continued to interact with two familiar adults.
Parental involvement in the CASP is highly desirable, but recent feedback
from EIs indicated that some parents may not be available at every testing
interval. In this situation, two EIs were allowed to administer the CASP if
both are familiar to the child. For both of these modifications, it is essential
that two adults be involved, the number of models for each stimulus item be
held constant, and reinforcement be given as in the instructions.
Implications for Assessment and Intervention
During field testing, the CASP was re-administered 10 months after the
first administration. We recommend that CASP be given more frequently in
clinical practice. Administering the CASP at 2-, 3-, or 4-month intervals will
enable EIs to monitor progress more closely and collect more information on
children who are suspected of having auditory, speech, or learning difficulties. In addition, children with CIs and properly-fitted HAs may make relatively rapid advancements in vocal development soon after their devices are
activated (e.g., Ertmer et al., 2007). Frequent administration of the CASP is
needed to monitor changes across the first year of sensory aid use. Articulation tests are recommended to replace the CASP once children approach
ceiling levels and begin to say words on a regular basis.
71
In addition to evaluating progress in vocal development and sensory aid
benefit, the CASP can provide information for intervention planning. CASP
scores reveal whether the precanonical, basic canonical syllables, and advanced forms levels are established, emerging, or unachieved. This information can be used to select developmentally appropriate speech goals for
individual children. Ertmer and colleagues (2002) proposed an intervention
approach called Short Periods of Prelinguistic Input (SPPI) to stimulate
speech development in infants and toddlers who have hearing loss.
The purpose of SPPI is to stimulate auditory perceptual development and
help children advance through the levels of vocal development in an appropriate way. Using this approach, parents and EIs provide repeated modeling
of target vocalizations from the child’s current level of vocal development
before introducing later-emerging vocalizations. The spoken models are provided five times a day during one-minute periods of vocal play between the
child and a caregiver. During these short stimulation periods, the parent
repeats a developmentally appropriate speech target (e.g., isolated vowel, CV
syllable, CVC syllable) once every five seconds. This procedure allows the
child to hear the target repeatedly and provides opportunities for imitation
between models.
Ertmer and colleagues (2002) offer five reasons to target prelinguistic vocalizations. First, children who are developing typically produce simple and
then increasingly complex vocalizations before they say words on a regular
basis (Nathani et al., 2006; Oller, 1980; Stark, 1980). Therefore, earlier emerging vocalizations are likely to be easier to imitate after sensory aid fitting than
more complex productions, such as words. Second, the acoustic characteristics of speech sounds are highlighted when they are repeated aloud in isolation or in phonetically simple combinations. Third, targeting vocalization
types that are at or slightly above a child’s current developmental level increases the likelihood of imitation and learning. Fourth, speech production
practice can enhance auditory perception after sensory aid fitting. Osberger
(1983) demonstrated that the ability to verbalize speech patterns actually
preceded and facilitated auditory perception of the same patterns. Thus, concentrated modeling of prelinguistic vocalizations has the potential to stimulate growth in speech perception as well as speech production ability. In
addition, watching lip movements and listening to repeated models of speech
production may help children associate sounds with the visible speech movements needed to produce them. Finally, targeting nonmeaningful vocalizations during vocal play enables children to focus on speech and listening
without the cognitive load associated with learning and producing words.
SPPI should be considered as a supplement to the spoken language stimulation that parents provide throughout the day.
Although the efficacy of SPPI has not been tested directly, it is supported
by research showing the positive effects of concentrated modeling on infant
72
speech (Kuhl & Meltzoff, 1996); by previously proposed models of intervention with toddlers (Stark, 1989); and by the use of concentrated modeling, a
well-accepted intervention technique in the field of communication disorders
(Leonard, 1992). For detailed descriptions of SPPI, see Ertmer et al. (2002) and
Ertmer (2005). Video demonstrations and further explanations of SPPI can be
accessed at www.vocaldevelopment.com (Ertmer & Galster, 2001).
Summary
The CASP was designed to be an objective, developmentally appropriate
and practical tool for assessing vocal development in very young sensory aid
users. Field testing revealed that CASP scores can be expected to increase
with age and sensory aid experience. Repeated administration of the CASP
can provide EIs with a time-efficient way to monitor progress in prelinguistic
vocal development and, by inference, auditory benefit from HAs and CIs.
CASP results can also be used to design systematic and developmentally
appropriate aural habilitation for infants and toddlers who have hearing loss.
Acknowledgments
The development of the CASP and the preparation of this article were
supported through grants to the first author from the National Institute on
Deafness and other Communication Disorders, National Institutes of Health
(R03DC04226 and R01DC007863). The contributions of Chrissy Miller, Jennifer Quesenberry, Alfred Mwamba, Kristin Abbey, Kristi Holly, Lauren Hendrickson, Kristin Vincent, and James Wilson are gratefully acknowledged. A
special thank you to Michele Wilkins and the staff of Child’s Voice for their
unwavering support of research to benefit children with hearing loss. And
last but not least, we are especially grateful to the children and parents who
participated in field testing.
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Appendix A: Directions for Administering and Scoring the
Conditioned Assessment of Speech Production
(CASP)
David J. Ertmer and Carol Stoel-Gammon
1. Warm-up Items
a. After getting the child’s attention, the early interventionist (EI) models the first warm-up vocalization (/u/) while holding a toy reinforcer (e.g., a star-shaped piece for the Classical Stacker musical/
light-up ring-post toy) next to her mouth. Models are spoken at
slightly louder than conversational intensity level and without unusual visual or intonation cues. The clinician says /u/ or “Say /u/”
while looking at the parent.
b. The parent imitates the modeled vocalization. The parent is given the
reinforcer and places it on the post. Parent and EI respond enthusiastically as the stacker toy lights up and plays a few musical notes.
c. The parent gets the child’s attention and models the same vocalization (i.e., /u/ or “Say /u/”) while holding the toy reinforcer next to
his or her mouth and looking at the child. When the child vocalizes,
he or she is praised and allowed to place the star on the post. Any
vocalization is reinforced. To maintain a game-like situation, the child
is allowed to place the star on the post even if he or she has made no
attempt to imitate.
d. If the child does not respond to /u/, repeat steps a–c with the warmup vocalization /o/. If the child attempts to imitate either warm-up
item, move to level 1.
NOTE: EIs may choose to modify these procedures if the child is familiar with
a different, previously established routine for eliciting speech (e.g., if the
reinforcer is typically given to the child before an imitative attempt). If the
child responds more consistently to the EI than to the parent, the EI and
parent roles can be reversed. Two familiar EIs can also administer the CASP
if parents are unavailable; however, the parent should participate in the process whenever possible. Three adult models are given before the child is
expected to imitate each item.
2. Testing
a. The EI models the first vocalization of level 1 for the parent as described in step 1a.
b. The parent imitates the vocalization and receives a star reinforcer.
c. The parent turns to the child, gets his or her attention, and models the
vocalization while holding the star next to his or her mouth. The child
imitates the model.
76
d. All of the child’s imitative attempts are praised and reinforced immediately. The EI transcribes the child’s response in the space provided on the score sheet.
e. If the child’s production is fully acceptable (receives 2 points), go to
the next stimulus item and repeat steps 2a–d.
f. If the child does not respond or the imitative response is not fully
acceptable, note NR (no response) or transcribe the child’s original
attempt on the first line under the stimulus item.
i. Repeat steps 2a–d with the same stimulus to give the child a
second chance. Transcribe and score the child’s second attempt.
ii. Only one repetition is allowed for each stimulus item.
iii. The star reinforcer is given even if the child does not respond.
g. Continue introducing other stimulus items as in steps 2a–d until all
the items at level 1 (precanonical) have been presented to the child.
h. Present stimulus items from level 2 (basic canonical syllables) using
the procedures in steps 2a–g.
i. If the child scores at least 1 point on level 2, present stimulus items
from level 3 (advanced forms) following steps 2a–g. Testing may be
discontinued if the child does not receive any points on level 2 and
the parent reports that the child rarely produces canonical (CV) syllables. If the child is reported to produce canonical syllables, present
all stimulus items
3. Scoring
a. Scoring criteria are given on the score sheet.
b. If more than one imitation is elicited, score only the most acceptable
imitative response (i.e., the response with the highest score).
c. Compare the child’s productions with the parent/clinician’s model.
For example, an imitative production can be fully acceptable if it
matches a model that was slightly different from the intended target
(e.g., Mother says /tæk/ instead of /tk/ and child says /tæk/).
d. Add up the number of points for the total score.
4. Repeat Testing
The CASP can be given at 2-, 3-, or 4-month intervals. Compare results
with previous scores for the same child.
77
78
1. No response
2. Two or more vowels that
do not match target
3. Response is not a vowel
(e.g., squeal, raspberry,
click, /m:/, /s:/)
4. CV syllable(s) without
target vowel (e.g., /bu/)
1. No response
3. Syllables with vowels that
do not match target (e.g.,
/bu/)
2. Two high-front
vowels: (/i/ /i/)
1. ______________
2. ______________
0 Points
1. Prolonged central
vowel
in isolation: //
1. ______________
2. ______________
Stimuli for Models
Transcribed
Responses
Level 1: Precanonical Vocalizations
1. Two high-front
vowels in any
combination (e.g.,
/i/ or /I/)
1. One central
vowel
(i.e., /ɑ/ or //)
1. Two or more vowels that match
target
2. Single vowel that is not /ɑ/ or //
3. CV syllable containing target vowel
(e.g., /b/)
1. Single vowel that matches target
2. Two vowels that are not /i/ or /I/
3. Two vowels, only one of which
matches the target (e.g., /i/ //)
4. CV syllables containing target vowel
(e.g., [bibi])
2 Points
1 Point
Score
Child’s Name ____________________________________ DOB _________ CA _____________ Date _______________
Parent _______________________ Clinician _____________________ Sensory aid type _____ Months of sensory aid use ______
Directions for parents: I am going to say some sounds for you to imitate. Then you will say the same sounds for your child
to imitate. Try to say the sounds in the same way and at the same loudness level that I use. We will give (child’s name) toys
and praise for playing this game with us.
Warm-up Sounds:
/u/: Child imitates readily __________ Imitates after pause __________ No response ________
/o/: Child imitates readily __________ Imitates after pause __________ No response ________
Appendix B.
David J. Ertmer and Carol Stoel-Gammon
79
1. No response
3. Syllables with vowels
that do not match target (e.g., /bu/)
3. Three low-front
vowels:
/æ/ /æ/ /æ/
1. ______________
2. ______________
1. No response
2. Vowel without
consonant
1. No response
2. Vowel in isolation
3. Consonant in isolation
1. No response
5. CV syllable with
bilabial nasal:
[mɑ]
1. ______________
2. ______________
6. CV syllable with
bilabial glide:
[wɑ]
1. ______________
2. ______________
0 Points
4. CV syllable with
bilabial stop consonant: [bɑ]
1. ______________
2. ______________
Stimuli for Models
Transcribed
Responses
Level 2: Basic Canonical Syllables
0 Points
Level 1 Cont.
1. CV syllable in which only the C or
the V matches the model
2. Two or more matching CVs (i.e.,
[wɑwɑwɑ] or [w w]
3. CVC syllable with matching C or V
2. Two or more matching CVs (e.g..,
[mɑmɑmɑ] or [m m])
(e.g., [bi] or [kɑ])
2. Two or more matching CVs (e.g.,
[bɑbɑbɑ] or [pɑp])
1 Point
1. Single /æ/ or /␧/
2. Two matching vowels (e.g., /ææ/
or /␧␧/)
3. Three vowels, only one /æ/ or /␧/
4. Two or three nonmatching vowels
(i.e., none are /æ/ or /␧/)
5. CV syllables containing target vowel
(e.g., [bæbæbæ])
1 Point
1. A single CV with
a /w/ and /ɑ/
or // (i.e., [wɑ]
or [w])
1. A single CV with
a bilabial nasal
consonant and
/ɑ/ or // (i.e.,
[mɑ] or [m])
1. A single CV with
a bilabial stop
consonant and
/ɑ/ or // (i.e.,
[bɑ], [pɑ], [b], or
[p])
2 Points
1. Three low- or
mid-front vowels
(i.e., /æ/ or
/␧/)
2 Points
Score
Score
80
1. No response
3. Isolated consonant (e.g.
[s])
4. VC or CV syllable
10. CVC: [tk]
1. ____________
2. ____________
No response
Isolated vowel
Isolated C (e.g., [m])
CV without a diphthong
Nonmatching diphthong
(e.g. /aU/)
1.
2.
3.
4.
5.
0 Points
9. C+ diphthong
syllable: [naI]
1. ______________
2. ______________
Stimuli for Models
Transcribed
Responses
Level 3: Advanced Forms
2 Points
1. A single CV with
/s/ or /s/ and [ɑ]
or // (i.e., [sɑ],
[zɑ], [s], or [z])
1. A single CV with
/k/ or /g/ and
/ɑ/ or // (i.e.,
[kɑ], [gɑ] or [k],
[g])
2 Points
1. CVC syllable with nonmatching Cs
and V (e.g., [pip])
2. CVC syllable with one or two segmental errors (e.g., [tɑp])
Total Score
1. CVC syllable with
initial /t/ or /d/
and final /k/ or
/g/ combined
with /ɑ/ or //
(e.g., [tk], [dg],
[tɑk], [dɑg])
1. /n/ plus match1. Matching diphthong in isolation
ing diphthong
2. /n/ + nonmatching diphthong (e.g.,
(i.e., [naI])
[noI])
3. Nonmatching C with matching
diphthong (e.g., [maI])
4. /n/ plus vowel (e.g., [na])
5. CVC syllable with /n/ and [aI]
(e.g., [naIk])
1 Point
[sss] or [zɑzɑ])
8. CV syllable with 1. No response
lingua-alveolar
fricative: [sɑ]
3. Consonant in isolation
1. ______________
2. ______________
1 Point
[gɑgɑgɑ] or [kk])
0 Points
7. CV syllable with 1. No response
velar stop: [kɑ]
1. ______________ 3. Consonant in isolation
2. ______________
Level 2 Cont.
Score
Score
The Volta Review
ISSN 0042-8639
The Volta Review
Alexander Graham Bell Association
for the Deaf and Hard of Hearing
The
Volta
Review

this issue - Alexander Graham Bell Association

Transcription

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