3. 74 7th Asia Pacific Symposium on Cochlear Implants and Related Sciences – APSCI
tion and 4) support parents so they gain confidence in their own ability to support
their child’s learning.
This study aims to evaluate the efficacy of using the The LittlEARS®
Diary (Veek-
mans et al 2004) and Activities to Supplement the LittlEARS®
Diary (Kosaner 2009),
which use a naturalistic and observational approach, as a basis for comprehensive
and early parent guidance sessions.
Materials
The following tools were used to provide comprehensive PG sessions to document
the progress of the children as well as of the parents and to collect feedback:
a) The LittlEARS®
Diary comprises ‘My Diary’, a Parent Book, a Therapist Book,
a Diary Overview Sheet for Therapists, and First Words Lists. The Diary covers the
first 28 weeks after device fitting. It provides parents and therapists with valuable
information on the different stages of early child development. The Diary also in-
cludes information on 1) auditory, speech and language development, 2) parent-child
interaction strategies to facilitate auditory, linguistic and communicative development,
3) ways to increase incidental learning and 4) creating an optimal acoustic environ-
ment in the home. The questions in the Diary promote careful observation of child
behavior and encourage documenting their progress. The Diary also includes some
ideas for activities.
b) The Activities to Supplement the LittlEARS®
Diary comprise 28 activities that
are grouped to match a week in the Diary and a guide to adult-child play interaction.
Interacting with the child provides parents with an opportunity to practice techniques
discussed in the Diary. These activities were designed to benefit both therapists and
parents who often have difficulty finding suitable activities for very young children
who have limited abilities and short attention spans. Each activity is described in
detail, the required materials are listed and certain characteristic behaviors that may
occur in parent to child talk in optimally supportive language environments are tar-
geted. For examples, parents are recommended to use messages that are easy for the
child to understand by reducing semantic and syntactic complexity or to be atten-
tive to their child’s communication overtures. These and other examples are there to
help parents learn appropriate and effective communication and play techniques. The
activities are unstructured, inexpensive and require little preparation. Certain themes
and techniques are woven into each activity for example, gaining the child’s atten-
tion before presenting materials, allowing the child free access to toys (introducing
toys in sets), following the child’s interest and encouraging the child to pay atten-
tion to sound, etc. Some activities involve the use of new techniques, for example,
setting up a play scene before the child enters the room (e.g. activity 4: setting up a
washing line and hanging washing). Other activities have specific themes (e.g. week
5: saying rhymes and week 23: playing percussion instruments). However, many of
the activities are based on routine activities of the home enabling the parents to use
everyday situations to enhance their child’s spoken language skills.
These activities also come with play recommendations and tips for parents. Tips
such as, for example, to pick up on intentions signalled by the child and to follow
the child’s interest and allow the child to ‘lead’ the play.
c) The Parental Rating Scale comprises 16 statements to be filled in before and
4. 75Singapore, 1-4 December, 2009
after completing the parent guidance sessions and ten extra statements to be rated on
completion of the guidance program. Each statement is rated on a 1 to 5 Likert scale
(1 being total disagreement and 5 being total agreement with the statement). Each
family was asked to rate their agreement with the given statements.
d) The Therapist Rating Scale comprises ten statements to be rated on completion
of the guidance program. Each statement is rated on a 1 to 5 Likert scale (see above).
Each therapist was asked to rate their agreement with the given statements.
Methods
Six children (aged 13-23 months; average 20 months) were implanted with MED-
EL PULSARCI100
cochlear implants and fitted with MED-EL OPUS 2 speech proces-
sors. Together with at least one parent these children participated in 28 weekly, diary
based observational parent guidance sessions. Four of the six participating families
lived on a minimum income and the mothers had completed only five years of formal
education. The other two families were better off economically and the mothers had
completed eleven years of formal education. Three experienced therapists, each sup-
porting two families, conducted the guidance sessions. At each session, parent and
therapist shared the Diary information for the week, discussed questions/problems the
therapists recorded. The therapists then outlined the themed activity for the week and
explained the related targeted communicative behavior. The parent and child interacted
over the activity while the therapist observed and later offered advice and encourage-
ment. Parents filled in the Parental Rating Scale at the first and last PG session. The
therapists filled in rating scales only after completion of all 28 sessions. Informa-
tion on each child was analyzed week by week and their achievements (reached by
at least five of the six children) were tabulated. The First Word Lists of each child
filled in after 18 and 28 weeks of the program were also analyzed. The Rating Scale
responses of both parents and therapists were analyzed and the frequency of scores
and the mode of each question were calculated. All this was done by using SPSS for
Windows 15.0 software (Chicago, IL, www.spss.com).
Results
Table 1 shows the common auditory, receptive and expressive language achie-
vements for the children in the study over the 28 week period as recorded in the
summary of questions and specific observations leaflet. By week 2, parents reported
that their children were alerting to loud, clear sounds. By week 21, the children had
begun to understand some words (e.g. names of family members, body parts, and
animal or food names). By week 22, the children had started to babble and by week
24, they joined in vocally in songs and rhymes. By week 27, they reported that their
children located loud sounds, alerted to soft sounds and recognized many household
noises and the parents’ voices.
Common achievements were also derived from the analyses of the First Words
Lists. At 18 weeks post device fitting and of PG sessions, all children understood
more words than they could say. All children used exclamations such as ‘Ayy!’ or
‘Eee!’ and said ‘wee-wee’, ‘Daddy’, ‘Bye bye’, ‘food’, and ‘baby’. After 28 sessions
of PG, all children could understand simple commands such as ‘take’, ‘bring’ and
5. 76 7th Asia Pacific Symposium on Cochlear Implants and Related Sciences – APSCI
Table 1: List of Weekly Achievements in at Least 5 of 6 Children
Table 2: Mean Score and Standard Deviation Values for Statements 17-27
6. 77Singapore, 1-4 December, 2009
used more words than prior to the program. Commonly used words were ‘give’, ‘take’
and the names of family members.
These results demonstrate that all the children in the study developed their auditory
and linguistic skills over the study period, but to varying degrees.
Parents’ responses on the parental questionnaire showed the positive impact gui-
dance had on them. From their responses, frequency tables revealed a mode score of
1 for questions answered prior to receiving PG. This indicates that most of the time
families disagreed with the statements. All six families disagreed with questions 6
(I involve my child in household activities like setting the table and tidying up), 8
(I look after toys and keep them in sets), 9 (I look at pictures and books with my
child), and 11 (I feel confident that I can help my child learn to talk). Parents’ re-
sponses after PG led to a mode score of 5 that indicates total agreement with most
statements. All six families agreed with questions 1 (I talk to my child in a normal
way), 2 (I talk clearly using a lively voice), 3 (I draw my child’s attention to sound),
4 (I provide my child with interesting sounds to listen to), 5 (I converse with my
child over routine activities like dressing and eating), and 14 (I feel that my child
is making progress).
Families were asked to answer a further set of ten questions upon completion of the
PG sessions. The mode score of these questions was again found to be 5 (indicating
total agreement). All families reported total agreement with questions 23 (Reporting
on developments each week encourages me to work with my child so that I can report
progress), and 27 (Changes in my behaviour have positively affected the behaviour of
other family members). There were only a total of 6% neutral or negative responses
for this section of the questionnaire. The descriptive statistics for questions 17 to 27
are given in Table 3.
The differences in mean scores between before and after guidance ratings of sta-
Table 3: Test Statistics for Statements 1-16
7. 78 7th Asia Pacific Symposium on Cochlear Implants and Related Sciences – APSCI
tements 1-16 can be seen in Graph 1. A Wilcoxon Signed Rank Test was carried out
to see whether these differences were statistically significant. Agreement was found
to be significantly higher after PG for all statements except numbers 8 (I look after
toys and keep them in sets), and 13 (I do not feel dependent on professionals to teach
my child) (all p values less than .05). The mean scores, z values and significance
levels for each statement are given in Table 2.
The three participating therapists totally agreed with all ten statements on the
Therapist Questionnaire. This indicates that they 1) benefited from the developmental
milestone information found in the Diary’s Therapist Handbook, 2) could use the
information from their Diary records and observations of parent-child interaction to
set appropriate habilitation goals and expectancies for both parents and children, 3)
found the records were useful in highlighting strengths and weaknesses and for sharing
information between professionals, 4) thought the activities were age appropriate and
interesting for young children, 5) found having new information and activities each
week contributed to the progress and high motivation levels of all participants, 6)
found existence of a program led to better planned comprehensive PG sessions, and
7) that using the program had extended their knowledge and skills.
Discussion
Parents’ very positive attitude to this guidance program may be because it provided
them with essential information and gave them the security that support would con-
tinue on a regular basis. At the start of the program, parents indicated disagreement
with statements 6 and 9. This may have been due to the children’s chronological age
as the parents may have thought that the children were too young to be involved in
household tasks or look at books. The only statement that most families did not agree
Graph 1: Mean Rating of each Statement before and after Parental Guidance
8. 79Singapore, 1-4 December, 2009
with even after guidance was no. 13 (I do not feel dependent on professionals to teach
my child). Although the families developed in many ways, they did still feel dependent
on a professional for guidance indicating the need for continued support well beyond
the first six months after implantation. Harrison and Roush (2002) reported that many
parents, especially in the first few weeks after diagnosis, want information about
how and when their child will learn to listen and speak. This type of information is
provided in the LittlEARS®
Diary. Another reason may be that record keeping allows
parents and therapists to notice even small developmental steps; this in turn keeps
up parental morale which is vital to maintaining a positive attitude. Cole and Flexer
(2007) state, “Often, early indications or clues of the child progressing are the most
effective and immediate catalysts for giant leaps in the parents’ ability to cope with
it all”. Enrollment in a program such as the one outlined here with LittlEARS®
also
gives parents the opportunity to meet other parents in a similar situation and benefit
from parent to parent support. The children in this study did show satisfactory auditory
and linguistic progress. Intervention at an early age and high parental involvement
were found to be the main factors contributing to child outcomes, as also outlined by
Moeller (2000). However, to prove this, outcomes for families receiving PG would
need to be compared with families in a similar situation not receiving PG. But the
ethics of such a study would be questionable.
Stredler Brown (2008) comments that intervention of children with hearing loss is
a relatively new profession and that providers often have to rely on in-service training
to meet quality standards. The fact that therapists felt that the use of the LittlEARS®
Diary and the Activities to Supplement the LittlEARS®
Diary increased their knowledge
and skills indicate the usefulness of these tools for the training of professionals.
Conclusions
Each parent and child pair progressed fairly equally throughout this 28 week pro-
gram even though the families had different social and economical backgrounds. The
children achieved similar abilities at similar hearing ages and their parents similarly
rated statements on the questionnaire. The parents ratings of the statements indicate
that they became more knowledgeable, confident, and skilful and most importantly
more involved with their child after participation in the PG sessions. Increase in child
outcomes and positive ratings of statements by parents and therapists suggest that
using the LittlEARS®
Diary and the Activities to Supplement the LittlEARS®
Diary
in combination with a naturalistic and observational approach in early intervention
lead to more positive outcomes for young implanted children and their parents. Fur-
thermore, the suitability of the tool as a means for the training of professionals has
been assessed.
References
Cole, EB & Flexer, C. Children With Hearing Loss - Developing Listening and Talking
Birth to Six. San Diego: Plural Publishing 2007.
Harrison, M & Roush, J. Information for families with young deaf and hard of hearing children:
reports from parents and paediatric audiologists. In: R.Seewald/J.Gravel (Eds). A sound
foundation through early amplification. Proceedings of the Second International Confer-
ence. United Kingdom: St.Edmundsbury Press 2002, pp. 233-251.
9. 80 7th Asia Pacific Symposium on Cochlear Implants and Related Sciences – APSCI
Kosaner, J. Activities to Supplement the LittlEARS®
Diary. Innsbruck: MED-EL GmbH
2009.
Moeller, M.P. Early intervention and language development in children who are deaf and hard
of hearing. Pediatrics,106, E43, 2000.
Stredler Brown, A. The Importance of Early Intervention for Infants and Children with He-
aring loss. In J.R. Madell/C. Flexer (Eds). Pediatric Audiology: Diagnosis, Technology,
and Management. New York/Stuttgart: Thieme 2008, pp. 232-239.
Veekmans, K., Kuhn-Inacker, H., Almadin, S., D’Haese, P. The LittlEARS Diary®. Innsbruck:
MED-EL GmBH 2004.
