COMMUNICATION BETWEEN HEARING PARENTS AND YOUNG CHILDREN WITH
HEARING LOSS: INFORMATION PARENTS RECEIVE AND UTILIZE TO SUPPORT
CHILDREN’S LANGUAGE DEVELOPMENT
By
Kalli B. Decker

A DISSERTATION
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
Human Development and Family Studies – Doctor of Philosophy
2015

ABSTRACT
COMMUNICATION BETWEEN HEARING PARENTS AND YOUNG CHILDREN WITH
HEARING LOSS: INFORMATION PARENTS RECEIVE AND UTILIZE TO SUPPORT
CHILDREN’S LANGUAGE DEVELOPMENT
By
Kalli B. Decker
Family-centered early intervention for children with hearing loss is intended to provide
parents with information about ways to strengthen interactions with their children that can
promote children’s language skills. Best practices within the field of early intervention suggest
that service providers should encourage parents to provide language-rich environments and use
specific language techniques; however, these best practices are stated in vague ways, and do not
provide specific examples of the information service providers should give to families. Research
provides details about what these language environments should be like: specific quantities and
qualities of parents’ language have been shown to predict the language skills of children with
hearing loss, such as parents’ use of a greater amount of different words (e.g., word types) and
certain language techniques (e.g., expansion). Furthermore, researchers have hypothesized that
information parents receive as part of early intervention may influence these quantities and
qualities of parents’ language; however, this has never been investigated. Therefore, the purpose
of the current research was to investigate the information that parents receive as a result of
participating in early intervention, and examine how this information was related to the
quantities and qualities of their language when they interacted with their children. Participants
were primarily recruited via early intervention service providers throughout Michigan.
Participants included 12 parents (11 mothers) who were hearing, and their children with
permanent hearing loss who were between 12-29 months of age (M = 21.6). Parents participated

in an interview about their experience with early intervention, and an observation of parent-child
free play. Study 1 examined parents’ reports of the information they receive from early
intervention service providers about how to promote the language development of their children
with hearing loss. Thematic analysis was used to identify patterns in the information parents
received. Results suggest that the information parents receive is partially in line with current best
practices within the field of early intervention, such as the importance of frequent
communication with their children during everyday activities. However, parents also discussed
the need for additional information and unbiased support about how to promote their children’s
language skills. Study 2 examined parents’ quantities of language and use of specific language
techniques during free play with their children, and how this related to their reports of
information received from their service providers. Relationships between these aspects of
parents’ language and other important contextual factors, family socioeconomic status (SES) and
children’s current language skills, were also examined. There was substantial variation in the
quantities of parents’ language, including overall talkativeness, and in their use of specific
language techniques. Parents’ use of parallel talk was related to their receipt of information about
the importance of frequently talking with their children throughout the day. Other patterns
indicated that parents of lower SES used more directives with their children, and children who
used a greater number of word types may elicit parents’ use of the language techniques shown to
promote their language development. Taken together, these studies reveal that the information
parents receive from early intervention is important to their language inputs when interacting
with their children with hearing loss. Furthermore, these studies demonstrate the importance of
providing parents with more nuanced information about the specific ways in which they can
support their children’s language development by building on their existing skills.

ACKNOWLEDGEMENTS

It seems unreal that my time in graduate school and at Michigan State University is
coming to a close. I cannot believe how fast the time has gone. I have many wonderful memories
from graduate school that range from deep, insightful conversations shared over a bottle of wine,
to middle of the night push-up challenges that still make me laugh. It seems like it was just
yesterday when I was an undergraduate teaching assistant for Richard Wampler, and he told me
that I had to go to graduate school. I am really glad I took his advice. Thank you for pestering me
all those years ago, Richard.
I have learned so much from the many wonderful people I have met throughout the years
in this program, including faculty and fellow students. I have also gained invaluable knowledge
from the parents and children with whom I have met as part of my research, as well as from the
early childhood teachers and individuals who are part of the early intervention community. The
knowledge that I gained along the way has led me to understand that my learning will never end,
and the expertise that I now have is only a small piece of a much larger picture; at the beginning
I found this overwhelming, but now I find comfort in knowing that my exploration via research
and teaching always has the possibility to help me acquire new knowledge and skills.
I am thankful for the academic ‘family’ I now have. Of my academic family, there is one
person who has been most influential. Claire, thank you for helping me find out who I am as an
academic without telling me who it is that I should be. I have known you for a quarter of my life,
and I frequently think about how fortunate I am to have spent these years working with someone
as knowledgeable and caring as you. You supported me while I searched for my niche, and you
continue to do so since as I still am in the process of figuring this out. I have learned so many

iv

things from you. You are an exceptional mentor and have created a wonderful space in which to
learn and explore. I am so thankful to know what it feels like to have a more experienced scholar
support me and care about my progress; it is my hope that I have learned this skill, and will treat
my students as well as you have treated me. Because of your unconditional support, I can forever
be known as your student who is responsible for the strategic placement of facial tissues in your
office. Graduate school, and life in general, was challenging at times. Thank you for supporting
me through these phases of my life. I look forward to your continued support as I transition
through the next phases of academic life.
I am also appreciative of the many other faculty members who have mentored me in a
variety of ways. Lori, thank you for supporting me as I was becoming a researcher; you
supported me as I was learning new skills and gaining additional experience outside of my direct
area of research. I will always remember the support you provided to me during my first year of
college teaching; it has shaped the teacher I am today. I am also greatly appreciative of your
honesty since I know that this means that I can count on you to help guide me during challenging
times. Dr. Carolan, thank you for being so welcoming and helping me navigate multiple stages of
graduate school. I have been able to come to you many times with questions and concerns, and
you have always helped guide me without telling me exactly what it is that I need to do. Dr.
Johnson, I am so appreciative that you have shared your knowledge and expertise with me
related to children with hearing loss. I frequently felt alone as I was learning about how to
support these children and their families. Thank you for providing guidance during these times.
I am also greatly appreciative of the learning experiences that I gained at the Child
Development Laboratories (CDL). Thank you, Laurie and Marisa, for welcoming me into the
CDL and providing me with opportunities to learn from some of the best early childhood

v

teachers in our community. My experience at the CDL was very meaningful to my graduate
career, and helped me understand how to be a better researcher and teacher, for young children
as well as my undergraduate students. The friendship that I gained from being at the CDL was an
added bonus. Marisa, thank you for being such a fun and supportive person to have in my life.
The research that I have done would not be possible without the time that my
undergraduate students have dedicated to spending on various projects. I have worked with so
many wonderful undergraduate students over the years. I am especially appreciative of Allie,
Becky, and Stephanie, who helped me collect data and complete many of the steps that were
necessary for this dissertation. I look forward to the day, in the not so distant future, when I can
be the one to call on you for your knowledge and experience.
I am also deeply appreciative of the funding that has made my time in graduate school
and my research for this dissertation possible. I have received generous funding and scholarships
from the Department of Human Development & Family Studies over the years, and because of
this, I have had the opportunity to do be part of many research teams and learn how to teach
undergraduate students. I am also appreciative of the funding that supported this dissertation
from the Early On Center for Higher Education and the Fahs-Beck Fund for Research and
Experimentation. The support from Early On and the early intervention community throughout
Michigan was key to successfully reaching families, and for this I am very appreciative. I also
wish to thank the families who were willing to share their time and experiences with me, and
welcome myself and my research assistants into their homes.
To my friends, both near and far, thank you for your support over the years. The graduate
students I have met have made this experience so much fun, even at times when it felt impossible
and never ending. Thank you to those who have kept me company during the many long, tedious

vi

hours of reading and writing that comes with graduate school. In particular, I am so thankful to
have met Ashley and Trish; I can always count on each of you to help me see the forest through
the trees, and you always help me find a reason to laugh hysterically. I am also deeply
appreciative of the friends I have made outside of graduate school who are part of the MidMichigan Food Club, especially Danielle and Darren. You helped bring perspective and balance
to my life at a time when I needed it the most. Knowing that I could count on you for a warm
meal and a really good laugh was deeply comforting.
Most importantly, I am thankful for the unconditional love and support of my mom, Dale.
Mom, thank you for encouraging me to find a path in life that makes me happy, and for
supporting me every single step of the way. You have always said that you wanted me to be able
to experience things in life that you never had the chance to, and I thank you for making
sacrifices so that I could go to college and pursue my interests. Your love and support means so
much to me. I am also thankful for the support and encouragement from my sister, Amber, and
my grandma, Virginia. Also, to my partner, Seth, who has provided me with love, empathy, and
support during the most stressful years of my doctoral program: thank you for helping me find a
sense of balance in my life and for always finding a way to make me smile.

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TABLE OF CONTENTS

LIST OF TABLES

xi

LIST OF FIGURES

xii

CHAPTER 1: INTRODUCTION
Purpose
Theoretical Framework
Rationale for the Current Studies
Aspects of Parent-Child Communication that Promotes Children’s
Language Development
Information Provided to Parents by Professionals
Best practices in the field of early intervention
Contextual Factors that Influence Parents’ Language Inputs
Chapter Summary
REFERENCES
CHAPTER 2: STUDY 1
Abstract
Introduction
Best Practices of Early Intervention
Parental self-efficacy
Unbiased information regarding communication choices
Supporting parent-child interactions
Information Provided to Parents by Professionals
Current Study
Methods
Early Intervention Services within the State of Michigan
Participants
Procedures
Transcription and Coding
Transcription
Reliability and validity
Coding
Results
Theme 1: The Importance of Talking Frequently, Particularly in the
Context of Everyday Routines and Activities
Subtheme: Effective speech, such as speaking clearly, may be
particularly important
Subtheme: Using signs to supplement frequent speech
Summary
Theme 2: Promoting Listening Skills and Language by Focusing on
Sounds
Theme 3: Incorporating Other Communication Channels

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1
1
1
5
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Theme 4: The Essential Role of the Parent
Theme 5: Parents Need Additional, Unbiased Information in Order to
Feel Supported
Subtheme: A need for more information and support related to
signs/sign language
Subtheme: The need for more specified information
Connections between Themes
Talking frequently is central to the information parents receive
Parents are important to their children’s language development;
therefore, they receive a variety of information to support their
children
Summary
Discussion
Alignment with Best Practices
Unmet Needs
Implications for Practice
Limitations
Future Directions
REFERENCES

57

CHAPTER 3: STUDY 2
Abstract
Introduction
Parent-Child Interactions and Children’s Language Development
The potential relationship between information provided to
parents and aspects of their language inputs
Contextual factors that influence parents’ communication
Current Study
Method
Participants
Recruitment and Procedure
Observation of parent-child free play
Parent interview
Transcription and quantitative observational coding of parents’
language techniques
Transcription and coding of parent interviews
Analytic Approach
Results
Study Aim 1: Descriptions of the Quantities and Qualities of Parents’
Communication
Quantities of parents’ language
Qualities of parents’ language
Study Aim 2: Associations between Parents’ Communication and
Information Received
Overarching patterns
Quantities of language input

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Higher-level language techniques
Study Aim 3: Associations between Parents’ Communication and
Contextual Factors
Family socioeconomic status
Children’s language use
Post-hoc Analysis: Parents’ Communication Modalities and Receipt of
Information about Signs
Discussion
Implications for Practice
Limitations
Future Directions
REFERENCES
CHAPTER 4: INTEGRATIVE CONCLUSION
Contribution to Existing Literature
Implications for Practice
Future Directions
REFERENCES

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x

LIST OF TABLES

Table 2.1 Demographic Information

42

Table 3.1 Demographic Information

100

Table 3.2 Definitions and Examples of Language Techniques Used to Code Parents’
Utterances, Noises, and Vocalizations

105

Table 3.3 Quantities of Parents’ Language Use during Free Play

112

Table 3.4 Excerpt from Free Play between Parent-Child Dyad 103

118

Table 3.5 Children’s Language Use during Free Play and Their Age in Months

125

xi

LIST OF FIGURES

Figure 1.1. Theory of change.

2

Figure 2.1. Thematic map of information parents receive from their early intervention
service providers.

49

Figure 3.1. Parents’ average use of specific language techniques (LTs) per minute. Lowerlevel LTs are above the line, and higher-level LTs are below the line.

113

Figure 3.2. Information parents receive about how to promote their children’s language
development.

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Figure 3.3. Parents’ average use of language techniques (LTs) per minute.

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Figure 3.4. Parents’ mean length of utterance (MLU).

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Figure 3.5. Parents’ use of parallel talk (PA) per minute.

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Figure 3.6. Parents’ use of open-ended questions (OQ), expansion (EX), and recast (RE)
per minute.

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CHAPTER 1: INTRODUCTION
Purpose
Communication between parents and children is important to children’s early language
development, and it is particularly important for children who have hearing loss since these
children are more likely to experience language delays compared to their typically hearing peers.
Family-focused early intervention is crucial to promoting the language skills of children who
have hearing loss, and an important component of these intervention services are intended to
provide families with information about ways in which to strength their interactions with their
children that can then promote their children’s language skills. However, we know little about
the information that is provided to families via early intervention service providers about
supporting the language skills of children who have hearing loss. There is reason to believe that
the information parents receive from their early intervention service providers may influence
aspects of parents’ language inputs with their children, but this has yet to be studied. Therefore,
this dissertation includes two studies for the purpose of investigating and contributing to the
existing literature related to: (1) the information that parents receive about how to encourage the
language development of their children with hearing loss, and (2) the ways in which parents of
young children with hearing loss communicate with their children, and how these aspects of
communication are related to the information that parents receive from their service provider(s).
Theoretical Framework
The overall goal of these studies is to better understand the interactions between parents
and their children who have hearing loss and what may influence these interactions, since aspects
of these interactions have the potential to lead to significant, positive changes in children’s
language development.

1

Figure 1.1, the theory of change for the current studies, outlines some of the steps that
can lead to the ultimate goal of promoting the language skills of children with hearing loss via
early intervention. The first step in providing high quality early intervention services to infants
and toddlers begins with a curriculum based on best practices, which are informed by research as
well as theories (Division for Early Childhood, 2014a; Shonkoff & Meisels, 2000; Odom &
Wolery, 2003); ideally, these best practices then directly influence the early intervention services
that families and their children receive, including the information that is provided to families and
the ways in which services are delivered.

Best practices (based on
research and theories)
Early intervention
services
Information provided to
parents
Parent-child
communication
Children’s language
outcomes

Contextual
factors

Figure 1.1. Theory of change.
A prominent theory about the foundation of human communication proposes that
language develops as a result of meaningful social and collaborative interactions with others, and
is motivated by individuals’ desires to request or share information (Tomasello, 2008). For this
reason, it is important that parents’ language focus on children’s interests or actions; it is in these
instances of joint attention that parents’ language inputs are most influential (e.g., Tamis2

LeMonda, Bornstein, & Baumwell, 2001; Lederberg & Prezbindowski, 2000). Therefore, it is
necessary to understand what may influence aspects of parents’ language, including the
information they receive as part of early intervention services when their children have a delay or
disability.
Researchers have hypothesized that the information provided to parents may have a
powerful influence on the quantities and qualities of parent-child communication, and
subsequently, children’s language outcomes (e.g., DesJardin, 2006; DesJardin & Eisenberg,
2007; Cruz, Quittner, Marker, DesJardin, & CDaCI Investigative Team, 2013; VanDam,
Ambrose, & Moeller, 2012; Ambrose, VanDam, & Moeller, 2014). To explain why the
information parents receive from early intervention service providers is so important and why it
may influence aspects of parents’ language with their children with hearing loss, a social
constructionism perspective informs this study. The theory of social constructionism posits that
our knowledge and how we construct meaning in the world is based on our interactions, such as
through our communication with others (Gergen, 1985; Lock & Strong, 2010). In the current
study, this relates to the information that parents report that they receive from their early
intervention service providers because it demonstrates that it is embedded in their memories and
potentially in their ways of thinking and actions. Social constructionism emphasizes that the
knowledge and meaning that individuals gain from social interaction often determines the ways
in which they choose to act (Burr, 1995); in the current studies, this suggests that the information
parents report that they have received from service providers can potentially influence their
actions, such as specific aspects of their language when interacting with their children. However,
the information provided to families as part of early intervention services, or how this may be
related to the quantities and qualities of parents’ language use, has yet to be investigated. In
3

particular, we do not yet know a) the content or variation in the information parents receive from
early intervention service providers, or b) the relationship between this information and aspects
of parents’ language input.
Study 1 will be the first to describe the information provided to parents through early
intervention services. Thus, it will provide a necessary foundational step in order to inform early
intervention practices by beginning to understand how the information provided to parents aligns
with best practices, including strengths and areas for improvements.
Study 2 is based on research demonstrating that certain aspects of parents’ language are
most beneficial for children with hearing loss, such as higher quantities of different words used
(word types), mean length of utterance (MLU), and conversational turns, as well as specific
qualities of parents’ language, such as the language technique of asking open-ended questions
(DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam et al., 2012;
Ambrose et al., 2014). However, what the field is lacking is an understanding of what explains
the variation in these aspects of parents’ language, including how this variation may relate to
information they have received as part of early intervention. Therefore, the value of Study 2 lies
in its ability to identify the relationships between aspects of parents’ language that are known to
be important and the information parents have received from early intervention service
providers.
Exploratory studies, such as these, provide the foundation for more specific, large-scale
explorations and replications. The results of these studies will also be used to understand parents’
experiences and the influences of early intervention services in a new way. By beginning to
understand the types of information that positively influence specific aspects of parents’

4

language inputs, these findings can inform best practices regarding the types of information
provided by early intervention service providers that are most influential.
Rationale for the Current Studies
Hearing loss can influence a number of developmental outcomes for children, but a great
deal of importance is placed on their language development. Research has demonstrated that
children with hearing loss have lower language skills compared to their typically developing
peers (Niparko et al., 2010; Barker et al., 2009); this domain of development is crucially
important because a delay in language skills can lead to a number of other adverse
developmental outcomes, such as lower academic achievement (Antia, Jones, Reed, &
Kreimeyer, 2009; Spencer & Marschark, 2010), more psychosocial difficulties (Dammeyer,
2010), and difficulties with socio-emotional skills (Hintermair, 2006; Spencer & Marschark,
2010). Approximately 90% of children with hearing loss have parents with typical hearing
abilities (Mitchell & Karchmer, 2004), and it is these children that are most at risk to experience
delays in language development for a variety of reasons, including difficulties with aspects of
parent-child communication because of unmatched hearing statuses (Meadow-Orlans, 1997),
such as the amount of time these dyads spend in joint attention (Meadow-Orlans & Spencer,
1996; Gale & Schick, 2009; Spencer, Erting, & Marschark, 2000). Therefore, a central aspect of
early intervention for children with hearing loss focuses on promoting their language
development (Moeller, Carr, Seaver, Stredler-Brown, & Holzinger, 2013; Centers for Disease
Control (CDC), 2015; Marschark, 2007; Joint Committee on Infant Hearing (JCIH), 2007;
Seaver, 2010) by strengthening aspects of parent-child communication and working directly with
parents to build their skills (Moeller et al., 2013; Spencer & Marschark, 2010; Division for Early
Childhood, 2014a, 2014b).

5

Aspects of Parent-Child Communication that Promotes Children’s Language Development
Children develop language based on their interactions with others (Tomasello, 2008), and
when these interactions are based on their interests and actions, this is when they are most
influential to children’s language development (Tamis-LeMonda et al., 2001; Lederberg &
Prezbindowski, 2000). Research related to parents’ language with both typically developing
children, as well as those with disabilities, suggests that higher quantities of parent language, in
the form of the different number of words (word types), mean length of utterance, and
conversational turns all positively relate to children’s language outcomes (Hart & Risley, 1995;
Huttenlocher, Haight, Bryk, Seltzer, & Lyons, 1991; DesJardin, 2006; DesJardin & Eisenberg,
2007; Cruz et al., 2013; VanDam et al., 2012; Ambrose et al., 2014). However, it is not just the
quantity of parents’ language that is important to children’s development; when parents’
language includes qualities that are responsive to what it is that children are doing or attending
to, it is parents’ language inputs during these interactions that are most influential. For example,
qualities of parents’ language that have been linked to children’s expressive and receptive
language skills include parents’ use of language techniques that include responses to children’s
vocalizations or discussions of what it is that their children are interested in or doing (TamisLeMonda et al., 2001; Girolametto, Weitzman, Wiigs, & Pearce, 1999; McNeil & Fowler, 1999;
Yoder, McCathren, Warren, & Watson, 2001; Dale, Crain-Thoreson, Notari-Syverson, & Cole,
1996; Cruz et al., 2013; DesJardin et al., 2014; DesJardin, 2006; DesJardin & Eisenberg, 2007).
Unlike the quantities of parents’ communication, which have shown that greater
frequencies are beneficial to children of all ages, different qualities of parents’ communication
are beneficial for children either at different stages in their language development, or because of
their hearing status. The literature demonstrates clear patterns of parent language techniques that

6

are important for typically developing children or those with language delays based on whether
children have language skills above or below that of a typically developing 24 month old, which
is when children typically transition from the one-word stage of language development to the
two-word stage (Girolametto et al., 1999; Tamis-LeMonda et al., 2001; McNeil & Fowler, 1999;
Dale et al., 1996; Yoder et al., 2001; Dale et al., & Cole, 1996). However, for children with
hearing loss, the qualities of parents’ language that are beneficial for their language development
do not differ based on their language age—instead, parents’ use of expansion, recast, open-ended
questions, and parallel talk have been shown to be beneficial (Cruz et al., 2013; DesJardin et al.,
2014; DesJardin, 2006; DesJardin & Eisenberg, 2007).
For typically developing children or those with language delays who are younger and
whose language age is under 24 months, the techniques of linguistic mapping, also known as
interpreting (putting the child’s verbalizations into words), imitation (imitating the child’s
verbalization), and expansion (adding to children’s language by adding words to make it a
complete sentence or thought) are shown to be important (Tamis-LeMonda et al., 2001;
Girolametto et al., 1999; Yoder et al., 2001). For example, in the Girolametto et al. (1999) study
with younger children who had expressive language delays, there was a positive relationship
between mothers’ use of linguistic mapping and expansion and children’s expressive language
skills. Children’s language skills were also positively associated with mothers’ use of imitation
(Girolametto et al., 1999). With young, typically developing children, the use of imitation and
expansion also predicts expressive language for young typically developing children (TamisLeMonda et al., 2001). Another study with younger children who had developmental disabilities
and delayed language skills demonstrated that mothers’ use of linguistic mapping when children
were 23 months on average was positively related to children’s expressive language at 29

7

months, and linguistic mapping at 29 months was related to both expressive and receptive
language at 35 months of age (Yoder et al., 2001). Thus, these studies suggest that the parent
language techniques of linguistic mapping, imitation, and expansion are facilitative of the
language skills for typically developing children and those with language delays whose language
age is below 24 months.
For typically developing children or those with language delays or developmental
disabilities who have a language age above a 24 month old, the language technique of expansion
is still beneficial for children’s language development. However, the use of linguistic mapping
and imitation no longer predict their language skills, and other techniques become important
including recast (repeating the child’s communication in the form of a question), and open-ended
questions (a phrase or a question that would require more than a one-word response). For
example, when mothers of 4-5 year old children with expressive language delays increased
certain aspects of their communication during book reading, such as the frequency of their
expansions and opened-ended questions, their children participated in more conversations and
the length of the children’s participation in those conversations was greater on average (McNeil
& Fowler, 1999). In another study with 3-6 year old children with language delays, parents were
taught to use dialogic reading (see Whitehurst et al., 1988; Dale et al., 1996), which encourages
parents to be questioning and information-giving listeners in order to support children’s language
development by becoming more active and engaged storytellers (Lonigan, Anthony, Bloomfield,
Dyer, & Samwel, 1999). They found that as a result of the training program, over the course of
approximately 6-8 weeks, parents increased their use of open-ended questions and expansions,
and children’s MLU and number of unique words they used increased significantly between the
pretest and posttest measures (Dale et al., 1996).

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In summary, the literature related to children who are typically developing, or those who
have language delays, shows that there are patterns in which parents’ use of certain language
techniques are most predictive of children’s language development, and these depend on the
child’s current stage of language development. Research suggests that parents’ use of linguistic
mapping and imitation are important for children’s language development when they are under
the language age of 24 months (Girolametto et al., 1999; Tamis-LeMonda et al., 2001; Yoder et
al., 2001) and that above a language age of 24 months, the language techniques of recast and
open-ended questions are most important (McNeil & Fowler, 1999; Dale et al., 1996); the
technique of expansion is important for these children, regardless of their language age (McNeil
& Fowler, 1999; Dale et al., 1996; Tamis-LeMonda et al., 2001; Girolametto et al., 1999).
The patterns of parents’ language techniques that are most beneficial for children with
hearing loss seem to differ compared to children who are typically developing or have language
delays. For children with hearing loss the pattern does not seem to vary based on the language
age of the child—instead, only the techniques of expansion, recast, open-ended questions, and
parallel talk are positively related to their language development, regardless of where they are at
in the development of language (Cruz et al., 2013; DesJardin et al., 2014; DesJardin, 2006;
DesJardin & Eisenberg, 2007); therefore, these are referred to as higher-level language
techniques. For example, Cruz and colleagues (2013) studied children who were 16.5 months on
average when they received a cochlear implant; the children and their parents were observed
interacting 2 to 4 weeks before the children received their implant and then at multiple time
points after implantation. Parents’ use of higher-level language techniques influenced children’s
expressive language growth, and approached significance for growth in children’s receptive
language, at 12, 24, or 36 months after children received cochlear implants. Contrary to what is

9

found for children who are typically developing or have language delays (Girolametto et al.,
1999; Tamis-LeMonda et al., 2001), parents’ use what they considered lower-level language
techniques, such as linguistic mapping and imitation, did not significantly influence children’s
growth in expressive or receptive language.
Similarly, DesJardin (2006) studied children with hearing loss who were between the
ages of 1 and 6 years old (M = 3.0 years) and found that mothers’ use of recast and open-ended
questions accounted for 23.3% of the variance in children’s receptive language and 24.3% in
their expressive language skills. Also, DesJardin and Eisenberg (2007) studied children with
hearing loss between 2 and 8 years of age (M = 4.8 years) whose language age was 30 months on
average; results showed that mothers’ use of recast was positively related to more advanced
receptive and expressive language development for children with hearing loss, and mothers’ use
of open-ended questions was positively related to the children’s expressive language
development (DesJardin & Eisenberg, 2007). Other studies of children who have hearing loss
show these same patterns: it is parents’ use of higher-level language techniques that promotes
their language development (e.g., DesJardin et al., 2014; Fung, Chow, & McBride-Chang, 2005).
This research, albeit limited related to infants and toddlers, suggests that regardless of a child’s
language age, if children have hearing loss then it is only parents’ use of higher-level language
techniques that promotes their language development, possibly because it provides children with
greater access to complex language and more opportunities to engage in the language
environment (Cruz et al., 2013).
In summary, studies demonstrate that specific quantities and qualities of parents’
communication are powerful factors that encourage both expressive and receptive language skills
of children with hearing loss. However, the Cruz et al. (2013) study is the only study to date to

10

include very young children with hearing loss who have younger language ages, and to examine
how their language development is influenced by their parents’ use of language techniques while
interacting with them, potentially because early identification and intervention is a relatively
recent change for the field of study related to children with hearing loss (e.g., National Center for
Hearing Assessment & Management, 2009; White, 2003). Because of the importance of parents’
language inputs when children are very young, Study 2 of this dissertation will expand on this
very limited literature by describing the quantities and qualities of parents’ communication with
infants and toddlers who have hearing loss.
Continuing to describe the aspects of parents’ language inputs with these children who
have lower language abilities is an important step in understanding how to promote the language
development of infants and toddlers with hearing loss; however, this is only one piece of the
picture. What is also needed is to understand what may influence the variation in parents’
quantities of language and use of these different techniques, given their importance to children’s
language development. Advancing our understanding of parents’ use of specific quantities and
qualities of language, and the factors that may influence these aspects of their language, will
provide an opportunity to inform best practices of early intervention for these children.
Therefore, Study 2 also investigates two important aspects of these families’ lives that may
influence the aspects of parents’ language that are known to be influential, specifically: the
information parents receive from their early intervention service providers, and contextual
factors of these families and their children.
Information Provided to Parents by Professionals
Based on variation in the effectiveness of early intervention, and variation in the
quantities and qualities of parents’ language with children who have hearing loss, researchers

11

have hypothesized that the information that parents receive from early intervention service
providers about how to encourage the language development of their children with hearing loss
may influence the aspects of their language when interacting with their children who have
hearing loss (DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam et al.,
2012; Ambrose et al., 2014). However, this has yet to be investigated and, in general, very little
known regarding the information that parents receive about how to encourage the language
development of their children with hearing loss.
Research shows that access to information is an important priority for parents
(Fitzpatrick, Coyle, Durieux-Smith, Graham, Angus, & Gaboury, 2007; Meadow-Orlans,
Mertens, Sass-Lehrer, & Scott-Olson, 1997), and they want information about how to promote
their child’s language development (Roush & Harrison, 2002) and what they can expect for their
children’s development of spoken language (Fitzpatrick, Angus, Durieux-Smith, Graham, &
Coyle, 2008; Fitzpatrick, Graham, Durieux-Smith, Angus, & Coyle, 2007). Yet, these studies
have not observed early intervention to explore the information provided to parents, or used
parents’ reports to examine specific information received, although this has been identified as a
priority for early intervention research (Alexander Graham Bell Association for the Deaf and
Hard of Hearing, 2013). Only one study to date has investigated parents’ reports of information
they have received, and this focused on information that parents receive from teachers about
shared book reading with their 3-5 year old children. The study found that parents receive
contradictory advice or incorrect information (to treat their child as if he/she is hearing), and
some parents reported that they did not feel as if the child’s teacher had advice to offer (Watson
& Swanwick, 2008). These findings demonstrate that the information parents receive may be

12

varied or incorrect, and this is in line with implications from previous research (e.g., DesJardin,
2006).
More research is needed to examine the specific information that parents report that they
receive via intervention about how to promote the language development of their children with
hearing loss, and whether this includes information about using the specific quantities and
qualities of language that have been shown to be important for the language development of
children with hearing loss. Therefore, Study 1 is an exploratory study that will investigate
parents’ reports of the information that they receive from their child’s early intervention service
provider about how to promote the language development of their infants and toddlers who have
hearing loss.
Although very little is known about the information that parents receive from early
intervention service providers based on observations of interventions or through parent report of
information received via such interventions (Alexander Graham Bell Association for the Deaf
and Hard of Hearing, 2013), there are other resources available for parents, educators, and
service providers. These other resources, especially those that outline best practices in the field
of early intervention overall, or as related to services specifically for infants and toddlers with
hearing loss, provide an idea of the general types of information that should be given to parents
(e.g., Division for Early Childhood, 2014a; Moeller et al., 2013; Yoshinaga-Itano, 2014).
Best practices in the field of early intervention. The recognition that meaningful social
interactions are important to language development (Tomasello, 2008) is evident in the
suggested best practices of early intervention for children with hearing loss, given that a
foundational aspect of best practices in the field of early intervention includes family-centered
services (Division for Early Childhood, 2014a; Moeller et al., 2013; Dunst, Trivette, & Hamby,

13

2007) and focuses on promoting positive parent-child communication (Moeller et al., 2013;
Spencer & Marschark, 2010; CDC, 2015a; Seaver, 2010). Family-centered intervention focuses
on appreciating and understanding the strengths and needs of each family, while empowering
them by providing information and opportunities to build their skills to support their child’s
development (Marschark, 2007; Division for Early Childhood, 2014b). Family-focused
intervention typically focuses on the context of typical, daily activities, based on the idea that
greater parental involvement in children’s day-to-day activities is linked to better child outcomes
and higher parental self-efficacy (Marschark, 2007).
Similar to overall best practices in the field of early intervention (Division for Early
Childhood, 2014a), the primary best practices that guide intervention services for children with
hearing loss focus on four main areas: 1) positive parent-child interactions, 2) parental wellbeing that can positively influence the child, 3) family involvement, including participation in
early intervention services and informed choices, and 4) parental self-efficacy (Moeller et al.,
2013). In order to encourage positive parent-child interactions, family-centered early intervention
focuses on providing parents with information and ideas that are relevant to their everyday
routines and activities with their children, and then giving parents opportunities to practice and
receive strength-based feedback about following through with these recommendations (Division
for Early Childhood, 2014a; Moeller et al., 2013; JCIH, 2007; Workgroup on Principles and
Practices in Natural Environments, 2008); this is also a way to build parents’ self-efficacy.
Supporting families to understand the important role they have in promoting their child’s
language development, and taking a strength-based approach to supporting families’ interactions
with their children (Division for Early Childhood, 2014a, 2014b; Moeller et al., 2013; Early
Childhood Outcomes Center, 2005), can not only help parents feel more confident, but also build

14

their skills (JCIH, 2007; Yoshinaga-Itano, 2014; Workgroup on Principles and Practices in
Natural Environments, 2008). An additional way that these best practices can support families’
self-efficacy, specifically as it relates to their feelings about their ability to make decisions about
their children with hearing loss, is to provide families with unbiased information and support
about their communication choices for their children (e.g., using signed and/or spoken
communication), regardless of the choices they make (Moeller et al., 2013; JCIH, 2007;
Yoshinaga-Itano, 2014).
Furthermore, best practices for this population focus on the aspects of parent-child
interactions that can promote these children’s language skills (Moeller et al., 2013; JCIH, 2007;
Yoshinaga-Itano, 2014) and providing parents with information that can help them promote their
children’s development (Division for Early Childhood, 2014b). In particular, service providers
are encouraged to support a language-rich family environment. However, recommendations for
ways in which service providers should encourage parents to create a language-rich environment
are vague. For example, resources for service providers discuss the importance of encouraging
parents to partake in activities and use specific strategies and language techniques that are known
to support the language development of children with hearing loss (Moeller et al., 2013;
Yoshinaga-Itano, 2014; JCIH, 2007); yet, these specific activities, strategies, and techniques are
neither defined nor discussed in a way that clarifies ways in which service providers can
encourage parents to interact with their children. These resources do include citations for
research that provide support for these recommended practices, including studies that show the
specific quantities and qualities of parents’ communication that are known to support the
language development of children with hearing loss, such as increasing the number of different
words children are exposed to and parents’ use of open-ended questions (e.g., DesJardin, 2006;

15

DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam, et al., 2012; Ambrose et al., 2014).
Given the vagueness of some of these best practices, this leads to questions about the information
that is provided to parents, since these best practices may not be specific or informative enough
for service providers to then be able to then provide detailed information to families.
Contextual Factors that Influence Parents’ Language Inputs
The influence of contextual factors in the lives of children and their families cannot be
underestimated; therefore, the studies in this dissertation take these into account. In particular,
families’ socioeconomic status, including family income and parental education, and the child’s
language skills are considered. These contextual factors have the potential to influence Study 1,
regarding the types of information that parents receive as part of early intervention services, and
Study 2, regarding how aspects of parents’ language may be influenced by family or child
characteristics.
Family socioeconomic status (SES) influences a variety of family and child outcomes,
including parents’ language inputs, which then influences children’s language skills (Hart &
Risley, 1995; Rowe, 2008; Hoff, 2003; for reviews see Bornstein & Bradley, 2003; Conger,
Conger, & Martin, 2010; Bradley & Corwyn, 2002). The foundational study by Hart and Risley
(1995) showed that two broad aspects of parents’ communication that are known to greatly
influence the language development of children, the quantities and qualities of their language,
are greatly influenced by their SES. In particular, children in higher SES families are exposed to
a greater quantity of parental language, and more supportive qualities, such as fewer
prohibitions; the quantities and qualities of language used by parents of higher SES were related
to children’s language skills and growth over time (Hart & Risley, 1995). Some of these same
patterns in how SES influences parents’ language inputs and children’s outcomes are similar for

16

children who have hearing loss, such as the positive influence of greater quantities of different
words that parents use when interacting with their children (e.g., Niparko et al., 2010; Barker et
al., 2009; Geers, Moog, Biedenstein, Brenner, & Hayes, 2009; Szagun & Stumper, 2012; Cruz et
al., 2013). However, SES has not been shown to influence parents’ use of higher- or lower-level
language techniques with children who have hearing loss (Cruz et al., 2013), which means that it
is not just higher SES families who may be able to use these qualities more frequently, and all
types of families may benefit from receiving information about these techniques.
Another important contextual factor that may influence parents’ language use with their
children is the child’s current language skills (e.g., Girolametto & Weitzman, 2002; TamisLeMonda et al., 2001; Goldin-Meadow, Goodrich, Sauer, & Iverson, 2007). Research has shown
that parents of children with hearing loss adapt their language inputs based on their children’s
language abilities (Farran, Lederberg, & Jackson, 2009), rather than their age alone (Lederberg
& Prezbindowski, 2000). This demonstrates that parents of children with hearing loss may
naturally adapt their language based on what may be most appropriate for their children’s current
skills and facilitative of children’s language growth. A number of studies suggest that the
quantities and qualities of parents’ language is what drives children’s language skills (e.g.,
DesJardin, 2006; DesJardin & Eisenberg, 2007; DesJardin et al., 2014); however, only one of
these studies was longitudinal and tested directionality. Cruz and colleagues (2013) found that
when children had better expressive language skills before they received their cochlear implants
at approximately 16 months of age, this predicted their parents’ use of more word types (number
of different words) and higher-level language techniques; both of these aspects of parents’
language were then shown to predict children’s later language skills. These research studies
suggest that parents are sensitive to their children’s language skills, and children’s abilities may

17

elicit specific aspects of parents’ language that then contribute to children’s continued
development.
Therefore, important contextual factors in the lives of children and their families should
not be ignored. Parents’ SES or children’s language skills are important to the ways in which
parents communicate with their children, and for this reason, they will be included in Studies 1
and 2 as factors that may influence may influence the quantities and qualities of parents’
language input.
Chapter Summary
Children with hearing loss may struggle to develop language skills that are similar to
those of their typically developing peers (Barker et al., 2009; Yoshinaga, Sedey, Coulter, &
Mehl, 1998; Moeller, 2000), and this is problematic given that these lower language abilities can
lead to additional adverse outcomes for these children (Antia, Jones, Reed, & Kreimeyer, 2009;
Dammeyer, 2010; Hintermair, 2006). Receiving early intervention services is known to be
important for the language development of children with hearing loss (Moeller, 2000;
Yoshinaga-Itano, 2003; Vohr et al., 2008), and parents are central to these early intervention
services (Division for Early Childhood, 2014a; Moeller et al., 2013; Spencer & Marschark, 2010;
Marschark, 2007). There is variation in parents’ language inputs, and questions remain about
how their language may vary as a function of the information they receive as a result of
participating in early intervention; this variation in parents’ language is important because it
subsequently leads to variation in the language skills of children with hearing loss (DesJardin,
2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam et al., 2012; Ambrose et al.,
2014).

18

Important factors that can positively influence the language skills of children with
hearing loss include specific quantities and qualities of parents’ language (DesJardin, 2006;
DesJardin & Eisenberg, 2007; Cruz et al., 2013; DesJardin et al., 2014), but only one study to
date has investigated these aspects of parents’ language when they interact with their infants and
toddlers who have hearing loss (Cruz et al., 2013). Furthermore, based on the theory of change
that guides this research (see Figure 1.1), there is reason to believe that parents’ language may be
influenced by the information they receive from early intervention service providers (DesJardin,
2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam et al., 2012; Ambrose et al.,
2014) or important contextual aspects of these families’ lives (Niparko et al., 2010; Barker et al.,
2009; Geers et al., 2009; Szagun & Stumper, 2012; Cruz et al., 2013; Farran et al., 2009;
Lederberg & Prezbindowski, 2000); however, this has yet to be studied.
For these reasons, Study 1 will investigate parents’ reports of the information they
receive from their early intervention service providers; Study 2 will explore the relationships
between the quantities and qualities of parents’ language and: a) the information they received
and b) contextual factors of these parents’ and children’s lives. Each study has the ability to
inform early intervention practices. Specifically, Study 1 can identify the alignment between best
practices and information that parents receive, and can elucidate whether the vagueness of the
stated best practices emerge within the information parents report that they receive. Furthermore,
Study 1 can also identify gaps between what research shows to be important for the language
development for children with hearing loss and information that parents receive, which can
inform future training efforts for early intervention service providers regarding the types of
information that may not be reaching parents. Study 2 has the ability to inform early intervention
practices by identifying how specific quantities or qualities of parents’ language are related to the

19

information they receive. In particular, Study 2 can begin to clarify the information that may best
relate to parents’ language use that are shown to be supportive of the language development of
children with hearing loss, or information that seems to be harmful. Overall, these studies will
fill important gaps in the literature that have the ability to better understand important aspects of
the lives of parents and their children who have hearing loss, and work toward building these
families’ and children’s strengths.

20

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21

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Seaver, L. (Ed.). (2010). The book of choice: Support for parenting a child who is deaf or hard
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Spencer, P.E., & Marschark, M. (2010). Evidence-based practice in educating deaf and hard-ofhearing students. New York: Oxford University Press.
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27

CHAPTER 2: STUDY 1
Abstract
Family-centered early intervention for children with hearing loss is intended to provide
parents with information about ways to strengthen interactions with their children that promote
children’s language skills. However, little is known about the information provided to families
within the context of early intervention. Therefore, this study used in-depth interviews to
examine parents’ (N = 12) reports of the information they receive from early intervention service
providers about how to promote the language development of their children with hearing loss.
Thematic analysis was used to identify the patterns in the information parents received as part of
early intervention. The results are discussed as they relate to best practices and research within
the field of early intervention. Results suggest the information parents receive is partially in line
with current best practices within the field of early intervention, such as the importance of
frequent communication with their children during everyday activities. However, parents also
discussed the need for additional information about how to promote their children’s language
skills.

28

Introduction
Children with hearing loss may struggle to develop language skills comparable to their
typically developing peers (Niparko et al., 2010; Barker et al., 2009), and these delays in
language development can lead to a variety of challenges in other developmental domains (e.g.,
Antia et al., 2009; Dammeyer, 2010; Hintermair, 2006). However, when children are identified
with hearing loss early and begin intervention at young ages, language skills are improved
(Yoshinaga-Itano, Sedey, Coulter & Mehl, 1998; Yoshinaga-Itano, 2003; Moeller, 2000; Vohr et
al., 2008; also see Leigh, Newall, & Newall, 2010 for a review). Nonetheless, even when these
children begin intervention at an early age, their language skills are lower, on average, than those
of children with typical hearing (Yoshinaga et al., 1998; Moeller, 2000; Niparko et al., 2010),
and the language gap between children with hearing loss and those with typical hearing becomes
increasingly larger as the age of beginning intervention increases (Moeller, 2000). The lower
language skills of these children, even when they begin intervention at very early ages, leads to
questions about which specific aspects of early intervention may support their language skills,
and which aspects may need to be improved.
Because of the language delays that many children with hearing loss experience, early
intervention for these children typically includes a strong focus on promoting their language
skills (Moeller, Carr, Seaver, Stredler-Brown, & Holzinger, 2013; Centers for Disease Control,
2015; Marschark, 2007; Joint Committee on Infant Hearing (JCIH), 2007). Resources for parents
and early intervention service providers suggest that the information parents receive about how
to encourage the language development of their children with hearing loss is critical (Marschark,
2007; Yoshinaga-Itano, 2014; Alexander Graham Bell Association for the Deaf and Hard of
Hearing, 2013), and may potentially influence aspects of parents’ communication which have

29

been shown to support the language development of children with hearing loss (DesJardin, 2006;
DesJardin & Eisenberg, 2007; Cruz, Quittner, Marker, DesJardin, & CDaCI Investigative Team,
2013; VanDam, Ambrose, & Moeller, 2012; Ambrose, VanDam, & Moeller, 2014). In particular,
higher quantities of parent language, in the form of unique words, conversational turns, and
mean length of utterance, all support the language outcomes of children with hearing loss (Cruz
et al., 2013; DesJardin & Eisenberg, 2007; VanDam, et al., 2012; Ambrose et al., 2014). The
qualities of parents’ language are also shown to be important; for children with hearing loss,
parents’ use of the language techniques of expansion (expanding upon the child’s
communication), recast (repeating the child’s communication in the form of a question), openended questions (a phrase or a question that would require more than a one-word response), and
parallel talk (discussing what the child is attending to or doing) have been shown to be beneficial
(Cruz et al., 2013; DesJardin et al., 2014; DesJardin, 2006; DesJardin & Eisenberg, 2007).
Previous research suggests that these aspects of parents’ language may be influenced by the
advice and information parents receive from early intervention service providers about how to
interact or communicate with their children (DesJardin, 2006; DesJardin & Eisenberg, 2007;
Cruz et al., 2013; VanDam, et al., 2012; Ambrose et al., 2014). In sum, the information parents
receive from service providers is an important aspect of early intervention to consider since it has
the potential to influence parents’ communication, and subsequently their children’s language
skills; this has yet to be studied in depth, and has been identified as a needed area of research in
order to better understand how the information parents receive as part of early intervention may
influence their ability to promote their children’s development (Alexander Graham Bell
Association for the Deaf and Hard of Hearing, 2013).

30

In addition to suggestions made in the literature, the theory of social constructionism
provides a framework to further explain why the information parents receive from service
providers is important and why it may subsequently influence aspects of parents’ interactions
with their children. The theory of social constructionism posits that our knowledge and how we
construct meaning in the world is based on our interactions, such as through our communication
with others (Gergen, 1985; Lock & Strong, 2010), and it emphasizes that the knowledge and
meaning that individuals gain from social interaction often determines the ways in which they act
(Burr, 1995). Therefore, this suggests that the information parents receive from early
intervention service providers may influence their knowledge about how to promote their
children’s language development, may be embedded in their thinking, and has the ability to
influence their actions, such as aspects of their interactions and communication with their
children.
Although little is known about the information that parents receive about how to promote
the language development of their children with hearing loss and how this may influence the
ways in which they interact with their children, reviewing the best practices for service providers
within the field of early intervention may provide insight as to the information that may be
provided to parents of children who have hearing loss.
Best Practices of Early Intervention
One of the foundational best practices of early intervention for children who have delays
or disabilities, including those who have hearing loss, is that the services are family-centered
(Division for Early Childhood, 2014; Moeller et al., 2013; Dunst, Trivette, & Hamby, 2007). A
family-centered approach to early intervention for these families includes, but is not limited to,
recognizing the family’s strengths and goals for their children, supporting parents’ involvement

31

in the program, and encouraging positive interactions between parents and their children
(Division for Early Childhood, 2014; Moeller et al., 2013; Spencer & Marschark, 2010;
Marschark, 2007). Previous research indicates that when early intervention includes familycentered practices, this is shown to positively influence children’s outcomes (Dunst et al., 2007;
Bodner-Johnson & Sass-Lehrer, 2003). In addition, when these services encourage families’
involvement with their child in a way that helps the child reach the goals the family has set for
him/her, these practices also influence parents’ self-efficacy, satisfaction with services, and
behaviors, such as their general parenting competence (Dunst et al., 2007).
Family-centered intervention is based upon the recognition that parents are the most
important agents of change for their young children with disabilities, rather than early
intervention service providers (Dempsey & Keen, 2008; Workgroup on Principles and Practices
in Natural Environments, 2008); consequently, early intervention is intended to increase parents’
confidence and skills regarding their ability to support their children’s development (Division for
Early Childhood, 2014; Moeller et al., 2013; Early Childhood Outcomes Center, 2005).
Therefore, in order to be most influential, family-centered services must include supporting
parents who can then support their children (see Dunst, 2009), since they are viewed as the
individuals who have the most potential to directly influence children’s day-to-day lives
(Dempsey & Keen, 2008; Marschark, 2007; Moeller et al., 2013; Early Childhood Outcomes
Center, 2005).
Recognizing the importance of children’s day-to-day lives as a learning context, familycentered intervention also focuses on individualization, such that families are provided with
services and supports that are relevant and applicable to their particular routines and activities
(Division for Early Childhood, 2014; Moeller et al., 2013; JCIH, 2007; Workgroup on Principles

32

and Practices in Natural Environments, 2008), and that are based on the specific strengths and
needs of each child and the goals of their family (Division for Early Childhood, 2014;
Marschark, 2007; DesJardin, Eisenberg, & Hodapp, 2006). Therefore, the goal is for service
providers to support families’ abilities to interact and communicate with their children in ways
that promote children’s development of language skills, and that can be done within the context
of their normally occurring day-to-day activities (JCIH, 2007; Yoshinaga-Itano, 2014;
Workgroup on Principles and Practices in Natural Environments, 2008). An additional priority
for family-centered early intervention services is to support parents’ decisions and goals for their
children. For families of children with hearing loss, this means that unbiased information should
be provided to families as they make decisions regarding the mode of communication they will
use with their child (JCIH, 2007; Yoshinaga-Itano, 2014).
In sum, services that are family-centered are intended to support positive parent-child
interactions and increase parents’ self-efficacy and competence related to promoting their
children’s development and making decisions about their children; more specifically, the support
provided to families is intended to be embedded within their day-to-day routines so that it can be
more applicable and easily incorporated into their lives. Below, each of these aspects of familycentered services will be discussed in more detail, since best practices in the field of early
intervention provide a foundation of understanding the type of information that may be provided
to families by their service providers.
Parental self-efficacy. Goals of family-focused early intervention include promoting
parents’ feelings about the important role they have in helping their children meet goals, and to
empower parents to be able to make well-informed decisions about their children (Division for
Early Childhood, 2014; Moeller et al., 2013; Early Childhood Outcomes Center, 2005), each of

33

which can build self-efficacy. Self-efficacy is an individual’s belief in their level of competence
or ability to perform a certain task (Bandura, 1977, 1989). Parental self-efficacy, beliefs about
the ability to competently parent children (e.g., Teti & Gelfand, 1991) or positively influence
children’s development (e.g., Coleman & Karraker, 1997), has been shown to positively
influence the ways in which parents interact with their children (Teti & Gelfand, 1991; for
reviews see Coleman & Karraker, 1998; Jones & Prinz, 2005).
For parents of children with hearing loss, self-efficacy is positively related to both the
quantities and qualities of mothers’ communication that are shown to promote their children’s
language development (DesJardin, 2006; DesJardin & Eisenberg, 2007). The Division for Early
Childhood (2014) outlines their recommended family-centered practices by using phrases about
how service providers should “support,” “engage,” and “work with” families (p. 8) since these
types of supportive, empowering relationships are intended to increase parental self-efficacy
(Moeller et al., 2013). Therefore, it is important that parents are provided with information that
demonstrates their critical role in the process of promoting their children’s language
development. One such way to demonstrate parents’ importance and role in this process is to
provide parents with information they can use and apply to their daily lives with their children
(Moeller et al., 2013), since this has the potential to positively influence parents’ self-efficacy,
which then influences parents’ interactions and communication with their children and,
subsequently, their children’s outcomes.
Unbiased information regarding communication choices. An additional aspect of
family-centered best practices includes providing families with unbiased information so that they
can make knowledgeable decisions that are in line with their values and goals (Division for Early
Childhood, 2014; JCIH, 2007; Moeller et al., 2013). Of particular importance for families of

34

children with hearing loss is the need for unbiased information related to possible modes of
communication—such as spoken and signed language, and the continuum of additional options
that are possible (JCIH, 2007; Yoshinaga-Itano, 2014). Choosing a method of communication
can be challenging for parents of children with hearing loss (Seaver, 2010; Kurtzer-White &
Luterman, 2003), and the information that parents receive from professionals plays an important
role in this process (Decker, Vallotton, & Johnson, 2012; Eleweke & Rodda, 2000; Kluwin &
Stewart, 2000). Therefore, it is important that families receive a range of unbiased information
about their choices and be openly supported regardless of their decision (Moeller et al., 2013;
JCIH, 2007); this unbiased information and support is important throughout the entirety of early
intervention, since parents’ communication choices are dynamic and may change over time
(JCIH, 2007).
Supporting parent-child interactions. Because of the importance of encouraging the
language skills of children with hearing loss this also means that family-centered early
intervention should support families’ abilities to provide language-rich environments (JCIH,
2007; Yoshinaga-Itano, 2014), including providing information about opportunities to
communicate with their children during everyday activities (Marschark, 2007; Moeller et al.,
2013). Strength-based approaches should be used to provide information about how families can
best support their child’s development (Division for Early Childhood, 2014; Workgroup on
Principles and Practices in Natural Environments, 2008). However, recommendations for service
providers about what constitutes a language-rich environment for children with hearing loss, and
ways in which they can support families to provide these environments, lack specificity and
detail. For example, service providers are encouraged to support parents’ use of language
techniques that have been positively linked to language development for children with hearing

35

loss (Moeller et al., 2013) and “provide strategies” that can support children’s language
development (Yoshinaga-Itano, 2014, p. 160)—yet the specific techniques or strategies are not
listed or described. Similarly, the Joint Committee on Infant Hearing (2007) recommends that
early intervention providers encourage parents’ involvement in activities that are known to
promote children’s language development; however, the specific information that should be
provided and activities that service providers should recommend are not discussed. Other
resources do mention some specific strategies; however, these recommendations are directed
toward the service provider, and are not discussed in a way that clarifies the information that
could be passed onto parents. For example, based on recommendations of the Division for Early
Childhood (2014), service providers are encouraged to use “language to label and expand” on
children’s interests or cues (p.12). Further, it is recommended that service providers interpret and
respond to children’s communication, regardless of whether it is verbal or non-verbal (Division
for Early Childhood, 2014).
In sum, the recommendations for the ways in which service providers can support parents
to provide a language-rich environment are vague. In addition, the resources that provide
recommendations to service providers do not explicitly discuss or explain the specific quantities
or qualities of parents’ communication known to support the language development of children
with hearing loss (e.g., Moeller et al., 2013; Yoshinaga-Itano, 2014). Recommendations for
service providers do provide citations to professional resources or original research that support
the suggestions given; however, the lack of complete transparency and description about
information or suggestions that should be provided to parents is problematic given that service
providers may struggle to interpret research findings (National Center for Education Research,
2015) or do not find them to be helpful (Zipoli & Kennedy, 2005; Campbell & Halbert, 2002).

36

Therefore, questions remain regarding the information that is provided to parents if the
recommendations that exist for service providers lack specificity and, therefore, may not be
particularly informative for the service providers themselves or for families if service providers
are subsequently providing vague information.
Information Provided to Parents by Professionals
Although a number of studies have focused on parents’ needs and experiences related to
early hearing loss detection, identification, and gaining access to intervention (e.g., Eleweke,
Gilbert, Bays, & Austin, 2008; DesGeorges, 2003; Fitzpatrick, Angus, Durieux-Smith, Graham,
& Coyle, 2008; Fitzpatrick, Graham, Durieux-Smith, Angus, & Coyle, 2007; Luterman &
Kurtzer-White, 1999), there is a dearth of studies that focus on the types of information parents
receive once they have begun intervention services. It is important to receive families’ input that
goes above and beyond measuring their general experiences and satisfaction; the information
parents receive as part of their involvement in early intervention services is a critical component
of early intervention that needs to be measured (Alexander Graham Bell Association for the Deaf
and Hard of Hearing, 2013).
One study found that parents’ rate access to information as an important priority, yet the
particular type of information that they desire was not specified (Fitzpatrick, Coyle, DurieuxSmith, Graham, Angus, & Gaboury, 2007). A few studies do report general information about
parents’ desires for information they would like to receive. For example, a study by Roush and
Harrison (2002) found a shift in parents’ priorities about the type of information they wanted to
receive at the time of their children’s diagnosis of hearing loss versus a few months after the
diagnosis. Immediately after diagnosis, parents wanted information related to understanding
what caused their children’s hearing loss and how to cope with the diagnosis. However, a few

37

months later, their first priority for information was learning how to promote their children’s
language development (Roush & Harrison, 2002). Another study also found that parents desired
specific information related to their children’s hearing loss, such as the medical aspects of their
hearing loss as well as information about what could be expected for the development of spoken
language (Fitzpatrick et al., 2008; Fitzpatrick et al., 2007a). Further, one study found that the
majority of parents receiving intervention services reported that they received information about
deafness, legal rights, child development, and options about their child’s future; parents were
asked about the service provided to them that they found to be most beneficial, and they ranked
the receipt of these types of information higher than other services such as classes, group
meetings, or individual counseling (Meadow-Orlans, Mertens, Sass-Lehrer, & Scott-Olson,
1997). These studies demonstrate that the content of the information parents receive as part of
early intervention is important to them. However, similar to recommendations on the types of
information that should be provided to parents, these studies only provide ideas about the general
topics of information provided to parents, rather than details of more specific information.
To date, there is one study that has more thoroughly examined parents’ reports of
information they receive, and this study focused on the advice provided to parents by teachers of
the deaf about engaging in shared book reading with their children (Watson & Swanwick, 2008).
Parents reported that they received contradictory advice about how to engage in shared book
reading with their children, and some received the message that they should treat their child with
hearing loss as if he/she had typical hearing. Many parents felt that their child’s teacher had no
advice to offer about shared book reading (Watson & Swanwick, 2008). These findings suggest
that parents may receive varied or incorrect information and suggestions about how to

38

communicate with their children, which is in line with implications from previous research (e.g.,
DesJardin, 2006).
The lack of more specific and accurate information may be due to the fact that very few
early intervention service providers are trained to work specifically with children who have
hearing loss (JCIH, 2007; Hands & Voices, 2005; Yoshinaga-Itano, 2003), even though early
intervention is crucial for this group of children (CDC, 2015; Seaver, 2010; Marschark, 2007). It
is of utmost importance that children with hearing loss receive services in a timely manner from
professionals who have appropriate training and skills (JCIH, 2007; Moeller et al., 2013;
Yoshinaga-Itano, 2014). This lack of trained professionals, in combination with vague
recommendations for service providers about specific information and suggestions for parents,
and the dearth of research that provides details about information given to parents, further
demonstrates that information provided to parents may be lacking, inconsistent, or too vague.
Based on best practices in the field of early intervention overall and as related to children
with hearing loss, parents should be provided with information about their role and importance in
promoting their child’s language development (Moeller et al., 2013; Yoshinaga-Itano, 2014;
JCIH, 2007). Implications from past studies (e.g., DesJardin, 2006; DesJardin & Eisenberg,
2007; Cruz et al., 2013; VanDam et al., 2012; Ambrose et al., 2014) and the theory of social
constructionism (Gergen, 1985; Lock & Strong, 2010; Burr, 1995), suggest that the information
provided to parents via early intervention service providers has the potential to influence their
communication with their children, and subsequently their children’s development. However,
only one study has investigated parents’ reports of information received (Watson & Swanwick,
2008), yet this focused on school-aged children who are past the critical age for early
intervention to support their language development. Therefore, there is a need for additional

39

research in order to better understand the information that parents receive at a crucial time in
their children’s language development, while they are receiving early intervention services
(Alexander Graham Bell Association for the Deaf and Hard of Hearing, 2013). In addition, there
are a variety of best practices that guide the field of early intervention; therefore, there is also a
need to determine how the information that parents receive aligns with best practices, since this
may inform future training and materials for service providers who work with families of
children with hearing loss.
Current Study
The current study is intended to provide a more thorough understanding of a particularly
important aspect of early intervention: the information that parents report that they receive via
early intervention service providers about how to encourage their children’s language
development and their role in the process of promoting their children’s language. Researchers
hypothesize that the specific aspects of parents’ language that positively influence the language
development of children with hearing loss may be influenced by the information parents receive
via their early intervention service providers. A limitation in the current literature is that very
little is known about the information parents receive and potentially internalize; this gap must be
addressed in order to understand how this information may influence the way in which parents
interact with their children and, subsequently, how this may influence children’s language
outcomes. This exploratory study will be a first step toward examining the information parents
report that they have received via early intervention and will also contribute to the existing
literature about how the information that parents receive aligns with suggested best practices in
the field. Therefore, the overarching question for this study asks: What information do parents
report receiving as part of early intervention services regarding how to promote the language

40

development of their children with hearing loss and their role in this process of supporting the
language development of their children?
Methods
Early Intervention Services within the State of Michigan
This section will briefly address early intervention services in the state of Michigan as
compared to other parts of the United States based on the Michigan Association of
Administrators of Special Education’s (2014) comparison of early intervention systems.
Michigan is one of five birth mandate states in the country, meaning that these states provided
services to infants and toddlers before Part C of the Individuals with Disability Education Act
(IDEA) was passed in 1986, which then mandated that services be provided to children under the
age of 3 who have delays or disabilities. Part B services of IDEA cover children 3-21 years of
age. Today all states, other than Michigan, use one set of criteria to determine eligibility for both
Part C and Part B services. Michigan has two levels of criteria for special education services—
meaning that children may be eligible for Part C services only, while others will be eligible for
both Part C and B services. In Michigan, children who are eligible for both Part C and B services
receive these services based on need and, at a minimum, receive 72 hours of services per year,
while children who are determined eligible for only Part C services receive varied frequency and
types of services and there are no minimum requirements for the amount of services provided
(Michigan Association of Administrators of Special Education, 2014). According to the Centers
for Disease Control, 32 children with hearing loss received early intervention services in the state
of Michigan in 2012 (Centers for Disease Control, 2014).

41

Participants
Twelve parents with typical hearing (11 mothers) and their children with hearing loss (7
females, M age= 21.6 months) participated in this study. All families were receiving in-home
early intervention services within the state of Michigan under Part C of the Individuals with
Disabilities Education Act; they had been receiving early intervention services for 15.4 months
on average at the time of the home visit (SD = 7.8). Each parent was the primary recipient for the
child’s early intervention services overall, but for two families the child’s nanny was frequently
the adult present for interactions with the child’s service providers. Children were 3.6 months of
age on average when they were identified with hearing loss (SD = 4.1) and 6.7 months when they
began receiving early intervention services (SD = 6.4). Children had varying degrees of hearing
loss; eight children were using bilateral hearing aids and 3 were using bilateral cochlear
implants. Children were 12.2 months of age on average (SD = 7.6) when they began using their
hearing devices. It should be noted that the child who was not using any type of assistance for
hearing had mild, unilateral hearing loss. Additional demographic information for parents, their
children, and families are included in Table 2.1.
Table 2.1
Demographic Information
Variable
Parent demographics (%)
Gender of participant
Mother
Father
Employment status
Stay-at-home parent
Working part time
Working full time
Education level
High school or GED
Some college
Associate’s degree
Bachelor’s degree

(N = 12)

91.7% (11)
8.3% (1)
33.3% (4)
33.3% (4)
33.3% (4)
16.7% (2)
25.0% (3)
8.3% (1)
16.7% (2)
42

Table 2.1 (cont’d)
Master’s degree
16.7% (2)
Professional or doctorate degree
16.7% (2)
Child demographics
Gender
Female
58.3% (7)
Male
41.7% (5)
Age of child when identified with hearing loss (months, SD)
3.6 (4.1)
Age of child when he/she first began receiving early intervention
6.7 (6.4)
services (months, SD)
Amount of time child has been receiving any type of intervention
15.4 (7.8)
services (months, SD)
Age of child at time of visit (months, SD)
21.6 (6.0)
Hearing loss
One ear
8.3% (1)
Both ears
91.7% (11)
Level of hearing loss in best ear when unaided
Mild (27 to 40 dB hearing loss)
33.3% (4)
Moderate (41 to 55 dB hearing loss)
16.7% (2)
Moderately Severe (56 to 70 dB hearing loss)
16.7% (2)
Profound (90+ dB hearing loss)
33.3% (4)
Use of hearing devices
Hearing aids for both ears
66.7% (8)
Cochlear implants for both ears
25.0% (3)
None
8.3% (1)
Family demographics
Household income before taxes
$12,000-19,999
25.0% (3)
$40,000-59,999
16.7% (2)
$80,000 or more
58.3% (7)
Race and Ethnicity*
White, non Hispanic/Latino
91.7% (11)
White, Hispanic/Latino
8.3% (1)
Parents’ reports of the mode of communication they and their child
use together
Spoken only
8.3% (1)
Mostly spoken, with minimal signing
41.7% (5)
More spoken, some signing
41.7% (5)
Spoken and signing equally
8.3% (1)
*Parents reported their own race and ethnicity and then separately answered the same
question for their child in order to consider whether the race or ethnicity of the child’s
other parent differed from that of the participating parent’s. In this study, the participating
parent and the child’s race and ethnicity did not differ.

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Procedures
To recruit participants, information about this study was primarily provided to families
via Part C services, which in Michigan is the Early On system (Michigan Department of
Education, 2013). Flyers about this study were provided to Early On county coordinators and
service providers, who then passed along the information to families. Information was also
distributed through social media networks and events for families of children with hearing loss in
Michigan. Criteria for being in the study included the following: (a) children had to be between
12 and 30 months of age, be enrolled in an early intervention program, and have no cognitive
delays or disabilities, and (b) both of their parents had to have typical hearing and use English as
their primary language. Families in which both parents were typically hearing were recruited for
this study, since research shows that these children with hearing loss are at greatest risk for
developing lower language skills potentially because the mismatch between hearing statuses may
create challenges for effective parent-child communication (Meadow-Orlans, 1997; MeadowOrlans & Spencer, 1996; Spencer, Erting, & Marschark, 2000). Children could have any degree
of hearing loss, and families could be using any form of communication with their children (e.g.,
signed, spoken, or a combination of both). Only one parent per family was asked to participate in
the study in order to make participation easier for families.
Once a parent contacted the principal investigator and was determined eligible to
participate, a home visit was set up; these visits took approximately two and a half hours. In
advance of the visit, parents were sent questionnaires to complete that included questions about
demographics and early intervention services in which they and/or their child participate. Visits
were arranged for a time and day that the parent chose. The home visits included the study

44

coordinator, a member of the research team, and the participating parent and child; sometimes
siblings were present as well. At the beginning of the home visit, participants were informed of
the nature of the study, their rights as participants, and their right to stop participating at any
time. This informed consent procedure followed the Institutional Review Board procedures of
Michigan State University. A semi-structured interview was used to learn about parents’
experiences with early intervention services, including their interactions with service providers,
including home-visitors, audiologists, or any other type of individual, service, or program they or
their child had participated in or were currently participating in related to the child’s hearing loss.
The interview protocol included asking parents questions about the information they have
received from service providers regarding: (a) how to interact or communicate with their child,
(b) how to promote their child’s language development, and (c) their role in promoting their
child’s language development. Parents were asked to provide specific examples of information
or suggestions they have received. These interview questions focused on the information that
parents reported that they had received, and is not a direct measure of information provided to
parents. However, for the sake of conciseness, in the results section of this study, parents’ reports
of information received will be discussed as ‘information parents received.’ Parents received a
$40 gift card and children received a book.
Transcription and Coding
In order to analyze the information from the semi-structured interviews, thematic analysis
was conducted by engaging in the phases of analysis that are outlined by Braun and Clarke
(2006, 2012).
Transcription. Following the analysis steps outlined by Braun and Clarke (2006, 2012),
first the interviews were transcribed by members of the research team. Both a video- and audio-

45

recorder were used to capture the interviews with parents, and were then used to create
transcripts. Brackets were added in the transcripts when identifying information needed to be
removed, such as names of individuals or agencies. Brackets were also used at times to clarify
the parents’ message, such as situations when reading the transcriptions of the data would lose
some of the meaning behind parents’ communication that was evident based on the audio and
visual data (e.g., exaggerated tones, the use of signs, etc.). After the interviews were transcribed,
they were double checked against the video data and re-read multiple times by the principal
investigator. In the excerpts presented in the results section, the interviewer’s comments (e.g.,
“Okay,” “Mhm,” etc.) have been removed, and in addition, […] is used to indicate that a portion
of the transcript has been removed for the purposes of providing a more concise example.
Reliability and validity. Multiple steps were taken to establish reliability for this study.
Although Braun and Clarke (2014) do not suggest that multiple coders are necessary for the use
of thematic analysis, additional members of the research team were involved during various
stages of the analysis (detailed below) in order to establish greater validity related to data
interpretation and validity related to the use of specific codes. In addition, the principal
investigator created memos after data collection visits, as well as during the process of rewatching the interviews, double checking, and re-reading the transcripts. Memos were also used
to keep track of ideas and patterns that came about during data collection and the qualitative
coding process, related to individual interviews as well as the project as a whole.
Coding. The qualitative approach of thematic analysis was chosen for this study because
of its flexibility; thematic analysis allows for the use of various theoretical positions and
purposes (Braun & Clarke, 2006). The purpose of this analysis is to provide a detailed account of
parents’ reports of the information they receive via early intervention, and to investigate the

46

complexity of themes, as well as the relationships between these themes. An additional purpose
is to explore the relationship between information parents report that they receive and how best
practices of early intervention for children with hearing loss.
An inductive approach was used, meaning that the codes were driven by the data and
were not determined a priori (Braun & Clarke, 2006). Initial codes were generated when the
principal investigator and a member of the research team separately re-read each of the
transcripts, and then met to discuss preliminary codes. Codes included short phrases or labels,
usually using the parents’ own words, to describe a specific type of information received; some
phrases or sentences were categorized using multiple codes when applicable (Braun & Clarke,
2012). After the preliminary codes were established, the principal investigator and a member of
the research team separately coded 3 of the videos and then met to check for consensus of the
usage of specific codes and to continue making adjustments to the coding by further refining
codes, adding new codes, and splitting others that were more nuanced. Using NVivo 10 software
(QSR International, 2014), the principal investigator then coded the transcripts, and continued to
refine the codes. Then the principal investigator met with a member of the research team to
discuss initial themes and a thematic map; themes included codes that could be grouped together
to describe general pattern of information parents reported that they received, and the thematic
map demonstrates the relationships between themes (Braun & Clarke, 2006). Refinement and
definitions of themes, as well as refinement of the thematic map, continued until the uniqueness
of each theme and richness of the relationships between themes became more precise (Braun &
Clarke, 2012).
During the coding process it became clear that although parents were not specifically
asked about what additional information they wanted, there were a number of instances across

47

interviews when parents discussed their needs for additional information or support related to
how they can promote their children’s language development. This was frequently discussed by
parents after they answered questions about the information they did receive or from other
questions during the semi-structured interview, since the interview included broader questions as
well (e.g., parents were asked about ways that early intervention could be improved, if there was
anything else that they would like to discuss at the end of the interview, etc.). Our research team
chose not to ignore this important aspect of the data when it included discussions about
information needed and/or not received, and, therefore, included this aspect of parents’
interviews into our codes and themes.
Results
Parents discussed a variety of suggestions or tips that they receive from service providers,
as well as information about the importance of themselves and other family members to their
child’s language development. Analysis of the data resulted in five primary themes; the thematic
map (see Figure 2.1) shows each of these themes and their relationship to one another. In the
thematic map, the main themes are outlined with solid black lines, and subthemes are outlined
with dashed lines. Four of these themes are related to the information that parents receive from
their service providers about how to promote their children’s language development, and the fifth
theme demonstrated parents’ needs for information or support in addition to what they have
already received. Importantly, nearly all parents’ interviews related to each of the five themes,
regardless of their children’s degree of hearing loss, use of or type of assistive devices, or the
primary mode(s) of communication parents reported using with their children.
The thematic map demonstrates the centrality of the information parents received about
talking frequently with their children during everyday activities and routines, since these are the

48

contexts in which their children will learn language (which is represented as an oval in Figure
2.1). Parents were also encouraged to focus on both letter and environmental sounds with their
children and take advantage of other communication channels, such as eye contact and touch.
Parents also received information about their importance to their child’s language development;
in the thematic map this is placed above the central theme of talking frequently because they
received information about how their interactions and communication with their children is what
provides the driving force behind their children’s language development. Parents also discussed
a need to receive additional information; parents reported that they need more information that is
specific to children with hearing loss, and additional information about the use of sign language.
In the sections below, each of the themes will be discussed individually in more depth, then the
more nuanced relationships between these themes and the overall representation of the data will
be explored.
Specific info
because of child’s
hearing loss

The parent is
essential, most
important
A need for more
Use effective
speech
(e.g., talk clearly)
Use signs to
supplement
speech

Info for learning
signs/sign
language

Talk frequently,
all throughout
the day

Focus on sounds,
hearing

Incorporate other
communication
channels

Figure 2.1. Thematic map of information parents receive from their early intervention service
providers.
49

Theme 1: The Importance of Talking Frequently, Particularly in the Context of Everyday
Routines and Activities
The theme that emerged as central, and most prominent to the information parents
received, is that they should be talking throughout all of the everyday activities and routines they
do with their children. Every parent discussed receiving information that related to the
importance of frequently talking with their children. This information was related to when and
where they should be talking with their children—and, essentially, that they should be talking as
frequently as possible throughout the day, regardless of where they are and what they are doing;
quite a few parents used the word “constantly” during portions of their interviews that related to
this theme, demonstrating the importance of frequency. It is important to note that when parents
discussed receiving information that is pertinent to this theme they nearly always used the word
“talk,” which demonstrated that this information was primarily about the spoken modality of
language, but they also talked about some of the information they received more generally, as
also related to their overall communicative interactions with their children. Parents received
information about a variety of ways that they could support them to talk frequently, such as
making sure to talk and narrate during routines and activities and slowing down their interactions
with their children; they also received information about using signs while talking, and the
importance of the spoken aspects of this frequent communication, such as articulation while
speaking.
In particular, parents received information about communicating during their everyday
routines, such as eating and getting dressed; they also received encouragement to engage in
common parent-child activities, such as reading and playing together, and to talk frequently
during these activities. For example, parents received general suggestions; one parent was told to

50

“read to her, and play with her, and talk to her.” (111), while another parent, when asked about
what she has been told about her role in promoting her child’s language development, this parent
responded, “Talk. Talk talk talk talk talk talk talk.” (103). Parents also received more specific
suggestions about “narrating constantly” (101), and ways to incorporate this into their day-to-day
routines in order to talk about what they or their children do. For example, when parents were
asked about suggestions they receive or information about their role in helping promote their
child’s language development, these were two typical responses:
Everybody through the program always says that no matter what you’re doing, you
should say everything that you’re doing. Everything. Because then, you know, eventually
he’ll pick up, especially the things once they really hear it, they’ll pick it up because
you’re constantly saying everything that’s going on: if you’re going to the grocery store,
if you’re driving, if you’re eating, if you’re brushing their teeth. Every single thing that
you do it should be constant language. […] Pretty much non-stop talking. […] No matter
what activity you’re doing, you should be saying everything you’re doing, describing
everything. (110)
[We’ve been told that] our role is to teach her the daily things. To teach her, ‘we’re
putting on your shirt,’ ‘we’re putting on your pants,’ ‘we’re going out the door,’ ‘look at
who’s home, daddy’s home,’ ‘look at the dog, feed the dog.’ So like, the daily life things
is our role; to teach her how to get through the day, and to communicate. […] Talk and
talk and talk and talk! Which is hard for some people, and it is, some days it’s really hard
for me. Like I find that I’m just handing her things and I’m like, ‘Why didn’t I explain
what I’m handing her?’ But that’s why [our service provider] reminds us of that. Because
we get in routines; parents get in routines, and we just do it and we don’t explain it. (104)
In addition, parents also received information about the importance of slowing down their
interactions with their children, which provides opportunities to use additional communication
during everyday routines or while they play together with their child. Parents were encouraged to
slow both themselves and their children down; instead of rushing through even regular or
mundane routines together, parents received information about the fact that these routines
provide an important opportunity to increase the amount that they talk with their children on a
day-to-day basis when they take the time to discuss these different aspects of their children’s

51

lives. The suggestions that parents received about slowing down was closely related to
information about how this provides opportunities for repetition. For example:
It’s kind of just a reminder to, ‘Okay, we need to slow down’ […] Because with [the
child’s sibling who has typical hearing] he just did it, so with [my younger child who has
hearing loss], it’s just kind of putting your mind set in different way. […] It’s just a lot of
repeating. […] So it’s like, ‘Let’s take time with this,’ ‘Let’s talk about the giraffe,’
‘What’s special about the giraffe?’ (112)
I just got to get him to stop and, you know, just try to focus and listen, and just the
language. That’s what I’m always told, just all that constant language—that is the most
helpful thing. And that’s what’s going to help him. And hearing everything over and
over, because it’s very repetitive. (110)
Subtheme: Effective speech, such as speaking clearly, may be particularly
important. As mentioned above, when parents discussed the receipt of information related to
this idea frequently communicating, they primarily used the word “talk,” indicating that this
information seems to be specifically about the use of spoken language. Further, parents did not
just receive information to talk, but that how they talk is important. Some parents discussed
receiving information about specific ways they should be talking with their child; they
mentioned receiving information about the importance of pronunciation, enunciation, or talking
clearly in general. Some typical examples include:
[They tell you that] you have to make sure that you say things—you’re pronouncing it
correctly or otherwise they’re not going to learn it correctly. I don’t want [my child]
saying it wrong or anything. (110)
Basically [our service provider] makes sure that we are being consistent. […] Like if she
doesn’t understand something to make sure to be insistent about the way we say
something to her. And to make sure like if she doesn’t understand it, sort of explain it or
just to be consistent with the way we do that. (108)
Subtheme: Using signs to supplement frequent speech. Some parents received
information about the use of signs, and to incorporate them into their frequent, spoken
communication with their child. A few parents received information about signs in the form of

52

specific demonstrations from their service providers. However, most parents received
information in the form of materials or resources about individual signs to use while talking,
rather than information or demonstrations about the use of sign language on its own or
simultaneously with speech. Parents discussed receiving information about signs, as if the
information was to help them learn an additional communication tool to supplement their speech,
rather than information that would help them learn a language that could subsequently support
their children’s language development.
Most of the information parents received about signs was not in-depth; for example,
parents received general information to use signs while speaking (e.g., “Just talking, and doing
the signs.” (102); “They have stressed the signing and speaking.” (107)). The majority of
information that parents received about signs was how to produce individual signs, such as
information in the form of handouts, booklets, or websites that included pictures or videos of
signs. For example:
They gave me the signs and stuff. They printed out like little booklets to work on. And I
immediately put them on the fridge; they’re still on the fridge to work on, and once she
gets it, to turn the page and work on the next few signs. (104)
Originally they gave me a flip book of some signs I can do. But I’m like, ‘Well that’s not
really gonna help me [because they are in a flip book].’ So I’m like, ‘Can you laminate
them separately? And then magnetize it? And then I can put it on the fridge.’ Because a
lot of the signs I do are ones like ‘eat’ and ‘more’ and that type of thing. (111)
So it wasn’t very frequent, but she would leave, like she left us information on the
signing, like where to look on the internet. (107)
Summary. Overall, parents are provided with information about how it important it is
that they use a lot of communication with their child, primarily through spoken language, all
throughout the day. Parents received information about the fact that everyday routines and
activities, which may seem mundane, are actually great opportunities for their children to learn

53

language, so they should talk all throughout these aspects of their day with their children. They
also received information about the use of signs during their frequent communication, but there
was a heavy emphasis on using speech, as further demonstrated by the next theme from parents’
responses.
Theme 2: Promoting Listening Skills and Language by Focusing on Sounds
Parents received information about discussing or drawing attention to the range of sounds
that are part of their children’s lives in ways that will help their children’s development of
listening skills; they received information about a variety of sounds to focus on, such as those
associated with spoken communication, sounds within the environment, or toys and other objects
that make noise. They also received information about different activities that they could do with
their children while playing together in order to support their child’s listening skills or
production of sounds or spoken language.
All parents discussed receiving some aspect of information that related to this theme
overall; however, one specific aspect of receiving information about focusing on sounds only
applied to children who were using hearing aids. In particular, the majority of parents whose
children were using hearing aids received information about the importance of their child’s
hearing aids and having the child wear them often; they received information that their child’s
ability to hear was crucial for the child’s language development. For example, when parents were
asked about the information they have received about what will promote their child’s language
development they said things like: “Wearing her hearing aid so she can hear the talk,” (102).
As for the rest of the information parents received that related to this theme, regardless of
their child’s use of a particular hearing device, many parents discussed receiving information
about promoting their children’s listening skills, both as it related to developing auditory skills in

54

general and for learning to then express language. Some parents received information about
drawing attention to different noises within their surroundings (e.g., “The speech pathologist
came to work with him and she said whenever you hear something, say ‘I hear it!’” (107)), and,
more specifically, to help their children listen for and recognize different words or letter sounds.
One example from a parent includes this aspect of focusing on letter sounds, which can help with
the children’s listening skills and encourage children to make sounds as well:
We’ve talked about like the, just some of the strategies to help promote, or some of the
listening activities to do to help. […] His speech therapist gave us like this little game
that was like turtles that had vowel sounds, like ‘ah ee oo’ […] so he could practice, he
has to listen to it. And then trying to encourage him to make the sound. (101)
Parents also received information about using objects, such as those that would be part of
everyday play, to help their child associate an object with a specific sound (e.g., “You would say
‘moo’ for the cow. ‘Grr’ for the bear.” (107)). Parents also said that they received information
about more specific types of activities to do, which could be incorporated into play. For example,
one mother, who had previously mentioned that her service provider had encouraged her to help
her daughter start producing the “K” sound, talked about receiving information about
incorporating this into play:
We started 'kick' and now she’s got it. […] A lot of [our time spent with the service
provider] right now is done outside just because that’s where [my daughter] likes to be.
You know we kicked the ball outside yesterday quite a bit. (103)
Other parents also discussed information that they received about specific ways to
incorporate sounds into their play with their children. For example, two parents talked about
being encouraged to use the sounds from Ling-6, which is a way to test children’s hearing across
the speech spectrum (Hope Cochlear, 2015); specific objects are matched up with sounds and
this can become a game for parents and their children to play together. One parent said:

55

The speech therapist has been good about giving us exercises to do with him […] like
some Ling-6 exercises. […] She was teaching me about like Ling-6 sounds, and like
showing me, how she had like different toys associated with each sound. (105)
Furthermore, some parents received suggestions of ways to help their child develop
specific skills so that the child could produce certain sounds associated with speech. For
example, a few parents mentioned receiving information about the importance of their child’s
ability to round their mouth, and ways that they could help their child develop that skill:
The one thing was drinking with straw. I never knew that helps form his tongue, help
work out his tongue to form letters and consonants. […] And they gave him a honey bear
with a straw. You know those honey bears with the straw? So that was one technique.
(107)
Theme 3: Incorporating Other Communication Channels
Many parents said they were encouraged to incorporate additional communication
channels into their interactions with their children. Communication channels include sound,
vision, touch, and smell (Hewett, 2012). Parents primarily received information about
incorporating the communication channel of vision, but they mentioned receiving information
about using touch as well.
Parents received information about paying close attention to eye contact, and their
proximity to their child so that he/she could see the parent’s mouth. Parents also received
information about being face-to-face with their child, such as during play or book reading
activities. Other parents talked about it more generally, for example:
One of the most important things is they like you to be at eye level with them so they can
see your whole face. It’s more personal and it’s just so they can watch you. You know,
and they’re focused right on you when you’re talking to them. Otherwise it is hard for
them to pay attention or even hear. (110)

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Some parents also discussed the importance of incorporating touch into their interactions
with their children, in an attempt to help their child understand that sounds come from the mouth.
This meant using touch in relationship to the parents’ mouth or the child’s mouth:
They just mainly tell us to work on trying to get her to say sounds, and when you are
trying to get her to say sounds you put your hand by her mouth so she can feel it. (102)
[One of the service providers told me] about different techniques to use, like putting her
hand up to my mouth when I say something. So that way she can kind of tell the way that
my mouth is doing it. (108)
One parent also received information about gently touching her daughter, so that her
child could understand that she was being loud. She said:
That is something they ask me frequently is, you know, ‘How’s it going’ and, ‘What’s
your hardest part of the day?’ […] [I tell them] she screams really loud! And so they have
worked with us on trying to find ways to work on that. So I put my finger up to her lip,
instead of yelling back at her. ‘Cause I was just making it worse. They’re like, ‘Oh just
put your, you know, just touch her. Touch her.’ And I’m like, ‘Yeah, that makes
complete sense. She’s a touch kid, why didn’t I think about that?’ (104)
Parents also discussed receiving information about using touch, as well as gestures, to
help direct the child’s visual attention and make connections with different sounds. The pattern
in the data related to use of gestures and touch was strongly associated with parents’ receipt of
information about focusing on sounds with their children; this will be discussed further in a
section below.
Theme 4: The Essential Role of the Parent
Parents discussed receiving information about their importance, specifically as it relates
to the crucial role they play in their child’s development. More specifically, some parents heard
that they are important because they are the ones with whom their child spends the majority of
his/her time, and with whom their children are most comfortable. In addition, they received
information about how important it was for them to be involved in multiple aspects of

57

intervention, such as following through with the suggestions made by service providers or
medical doctors, taking advantage of the resources that they have available for their child, and
advocating for the child. In relationship to parents’ role in early intervention, they received
information about their role as their child’s teacher (e.g., “That basically that I’m his number one
teacher, and that he’s gonna, I guess respond to me better than them just because he’s with me all
the time” (101)). Parents also received information about the importance of family as a whole,
including the significance of the child’s other parent and siblings. For example, when asked
about the information they received about what is influential to their child’s language
development one parent said mentioned herself and the child’s father and sibling, but also said:
“He’s got two sets of great grandparents and we have a nice big set of extended close friends that
are just cheering him on” (112). However, the overarching feature of this theme is that parents
were told that they were the most important individual in their child’s life, for example:
My importance? You know, they tell me that it is very important, that probably that I am
the most important, the parents and their home life because they are around us the most.
And to encourage them with their development. You know, just to know that, ‘You’re
doing a great job,’ and they’re always really supportive about everything that we’re doing
with her development. (106)
Parents discussed that their service providers were genuinely invested and cared deeply
for their children, but that they could also tell that the service provider viewed them, the parents,
as most important since the service providers also invested a great deal of time into the parentchild relationship.
Besides just checking on her […] they’re talking to me: ‘How are you doing? Are you
having any issues?’[…] And they’re showing me that I’m important. […] They’re very
focused on me and her. […] You can tell that her growth is important to them. You can
tell that they love her and they’re invested in her. They’re invested in me, and us as a
family, and her development and her future. (111)

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Furthermore, this was also evident because they were told that they are the individual
who is supporting the child the most, and their influence is much greater than that of the service
providers’. For example:
[My service provider] makes it very clear that, you know, [early intervention] is there to
help, but they’re there to help us help her. So, to make sure that we’re part of her
development, her language development. […] [She] has put it out there that if the family
and parents are not involved then it’s not going to go as good. (108)
Well, they’re here twice a month, at best twice a week. That’s only two hours a week. So,
if I don’t do it then it’s not going to get done. […] That’s what she said the first time she
came here, ‘We’re here this much [a few hours a week] and you’re here this much [all the
rest of the time].’ (112)
Theme 5: Parents Need Additional, Unbiased Information in Order to Feel Supported
This section focuses on parents’ discussions about the way that their experience of early
intervention could be improved, as specifically related to the information they receive. There
were two subthemes that dominated these discussions: the need for more information or support
related to the use of signs or sign language, and a need for more information that is specifically
related to the fact that their child has hearing loss. Importantly, it was not that certain parents
receive information while others receive barely anything; instead, this theme in the data is driven
by parents who discussed a need for additional information that would go above and beyond the
information they already receive.
Subtheme: A need for more information and support related to signs/sign language.
The majority of parents discussed using signs or sign language with their children, and many of
these parents also talked about their desire to receive additional information about this;
specifically, they discussed that they need additional information in the form of more instruction,
support related to the choice to use signs/sign language that the parent had already made, and
about using the complete structure of sign language rather than individual signs. The following

59

examples demonstrate the common patterns in parents’ interviews about the need for additional
instruction, or that the information would not be helpful to learn the language itself:
There’s just a lot of different signs that they do, but everything that they say they try to
use the sign for it. […] They ask us to try to use them while we play with her, which is
hard because I don’t know how to do them, but we try our hardest. (102)
When we started out with [our service provider] I said, ‘I wanna sign’ and they were like
‘Okay’ [the parent uses a hesitant, exaggerated tone that gives the impression of
uncertainty: ‘oooh-kay’] and so they tried, they tried really hard and that’s when they
gave me the pamphlets and stuff. (104)
Parents also discussed a lack of and desire for more support related to the use of sign
language, not just signs, but the complete structure of the language. Therefore, in order to try to
learn about the use of American Sign Language, these parents had to seek out their own
resources, one of which being videos that are primarily meant for children (e.g., Signing Time;
Two Little Hands Productions, 2015).
I think it would have been helpful if, I guess, if I could change anything—if I could have
got like assistance from early intervention in terms of learning sign language myself. That
was something we totally had to do on our own [through classes]. (105)
There’s no learning how to state a sentence or communicate, it’s just, ‘Are you guys
hungry? You wanna go have food?’ [signs ‘food’]. So it’s not […] ‘Go to the table,
there’s food time,’ [signs: ‘table,’ ‘food,’ and ‘time’], you know. So what I’ve learned
mostly is from Signing Time [videos]. (104)
Parents also discussed a desire for more support in two interconnected ways:
unconditional emotional support related to their decision to use sign language, as well as support
in the form of receiving additional information about how to continue with the decision that they
had already made about using signs/sign language. Some parents discussed that they did not feel
supported in their choice to use sign language with their children, and that their service providers
seemed biased toward the use of spoken language. For example, when asked about the receipt of

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conflicting advice, some parents talked not only about a lack of support, but also being
questioned about the choices their family had made:
I think it even got more conflicted because we’re choosing to move to [a new city], so
that he can attend the oral deaf program. And so then they’re like, ‘Well if you’re gonna
do all oral, why are you still doing sign [language]?’ And I was like, ‘Well, because he
really makes the connection with the oral if he knows the sign.’ So I don’t think people
quite understood that choice, and they just wanted me to do all verbal—just verbal,
verbal, verbal. (101)
Our teacher of the deaf and our speech therapist are pushing towards the oral program,
and we’re hesitant. We kinda want [him] to do the Total Communication. […] Our
teacher of the deaf, and maybe our speech therapist, are really focused on getting him to a
point where he can be mainstreamed, and that’s not really a concern of ours. […] We
really want him to be bilingual. (105)
Subtheme: The need for more specified information. Parents’ desires for more specific
information stemmed from the idea that their child is not just any child; their child has hearing
loss, and this is part of what makes their child unique and their needs as a parent unique. For
these parents, their child’s hearing loss meant that they felt there should be particular ways of
communicating or interacting with their children in order to support their language development.
Parents felt that they were not receiving this type of specific information, and this led them to
feel as if they information they receive “seems so unsophisticated” (106) and does not
completely meet their needs; they did not feel comfortable that they have enough information to
fully support their children’s language development. Some parents talked about this much more
than others; in one instance, one parent’s interview was dominated by her discussion related to
this theme of needing additional, specific information. This parent’s quote provides a variety of
examples that demonstrate what other parents mentioned as well:
[My child] has a special situation […] So I feel like I would like specific things that I can
do. […] ‘Is there a certain way I should do this?’ You know, ‘Is there a certain way I
should talk? Is there a certain way I should read to her? Is there a certain amount? Is there
a certain type of book?’ You know? Like there’s all sorts of little nit-picky questions.
[…] I think would really help me and empower me, and make me feel like I’m having
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more of an impact, because right now I just-, it’s not bad for her to feel like she’s any
child and I’m any parent. I mean that’s not a bad thing, but we do have a special situation
here that I need to be on top of. And I just kind of feel like I’m coasting along like
anyone else would that doesn’t have a special situation, and I don’t like that feeling. I
kind of feel powerless and I question everything, and I don’t have anyone telling me.
They’re telling me I’m doing good but they’re not telling me anything specific I can do
better, so I don’t feel like I’m doing better. (111)
Although not central to the guiding question of this study, a complex aspect of parents’
discussions must be noted—all parents talked positively about their service providers as
individuals and about the services that they receive. Frustration did not dominate the emotional
tone of interviews, with the exception of one participant (mentioned above) who discussed
multiple times, at length, about being irritated and disappointed about not receiving more
specified information. Even this particular parent, as well as all others who discussed a desire for
more specified or supportive information, an appreciation for the services was still discussed. For
example, one parent commented on both of these aspects—a desire for more specialized
information, but despite this, his appreciation of the services:
I don’t think they have a lot of exposure or experience with deaf children, and so it seems
like it’s geared more towards like, you know, just kids with other issues […] So I mean, I
guess overall, through no fault of their own they just, they’re not experienced with deaf
kids so we didn’t feel like they had too much to offer us. […] So I mean, they’ve been
wonderful. But as far, in terms of like working with him in terms of his hearing loss, you
know it’s hit or miss. […] I just hope I got across that like, you know, we’re generally
happy with early intervention. […] It’d be a great program for like, any other kind of
disability. (105)
Connections between Themes
The overall patterns in the information parents receive suggest the centrality of the idea
of frequently talking within the context of everyday activities and routines, and that parents are
foundational to why this matters—they are of utmost importance in their child’s life, and,
therefore, are encouraged to interact with their children in specific ways. However, parents desire
additional specific information about ways in which they can support their child, who is unique
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because of his or her hearing loss. These primary themes were related to one another, which also
helps elucidate the broader interconnectedness of the data (see Figure 2.1).
Talking frequently is central to the information parents receive. The theme of talking
frequently was related to each of the other primary themes. The information that parents receive
about the importance of frequently talking with their children included the additional
recommendations about what that communication should include, such as different sounds in the
environment and making sure that the child has access to a visual channel of communication. For
example, there are connections between the information parents receive about the importance of
talking frequently and the qualities of this communication:
Encourage the reading, and keep the talking, like when we talk to her just look, make
sure to look at her, talk clearly. […] You know, just make sure she understands the
words, don’t like turn and talk to her. Make sure you look at her and she knows you’re
talking to hear it. (109)
Parents’ importance was also closely connected to the central suggestion of talking
frequently. In particular, the reason that they receive this information about this frequent
communication is due to the fact that they, and their family members, are the most important
individuals in their child’s life, and therefore, have the ability to positively influence their child
by increasing their own amounts of language. For example, these are some common examples of
this:
[My service provider says] that I am key. That if I sit back and just let [my child] do it all
on her own and don’t work with her, you know, then she won’t get it as fast. She might
still get it, but it might not be as fast. Plus, the chances of lisp and talking differently are
less when we’re communicating with her and talking with her. (103)
They’ll send pamphlets reminding parents that, ‘You are the biggest influence!’ And, you
know, how can you be a bigger influence, and like I said earlier, they sent me a sheet
saying, ‘Read this book, and during the day don’t forget when you’re brushing her teeth
say ‘Brush, brush, brush!’’ […] If we’re silent, she’ll be silent. I mean, they always tell
you that a child is born with a clear slate and you’re the one that’s painting it. […] It’s,
‘You have that ability to teach her.’ (104)
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The interconnectedness of information about talking frequently, parental importance, and
focus on sounds was also evident in discussions of hearing aids. Parents receive information
about their role in this process—it is not only about having the child wear his/her hearing aids,
instead it is about the important role the parent plays in providing the child with additional access
to spoken communication, which then makes the hearing aids more valuable. For example:
They’re always telling me, even the audiologist tells me, how important I am and how
well I’m doing. Just because I’m trying, you know, ‘You keeping the hearing aids on him
all the time is very important, or just constantly trying just keeping that language
[going].’ That’s the biggest thing that they say. They say all the time, is the language.
(110)
One of the ways in which talking frequently was linked to other themes was through the
communication channels of touch and eye contact, and to use gesture to provide opportunities to
engage in eye contact. Recommendations about touch and gesture were ways in which parents
could draw attention to something in the environment, gain their children’s eye contact, and then
discuss it with their child. For example, parents talked about touching their own face or pointing
to something, which then provided an opportunity to make eye contact and talk about what is
going on around them:
They say always talk and point out things. […] So if [water was] running and they would
say, ‘Oh do you?’ Gestures is another big thing. ‘Do you hear the water running?’[puts
her finger to her ear]. And stop and listen or point to the water. So identify noises, and
just have a large variety of noises and sounds. (106)
Well this has been really helpful like, the first one we really got him to work on was [the
letter] B, we’d go ‘buh buh’ [making the B sound while touching her lips with her
forefinger]. Or with the horse we would go, ‘nay’ [while touching her nose with her
forefinger] […] Just kind of pointing, like getting his eyes on you. Like, ‘Where might
this sound come from?’ […] We have a sheet with the, ‘if you’re going to do a K sound,
you might want to get his eyes up here, looking at your mouth, and how you’re going to
do it.’ (112)
Parents are important to their children’s language development; therefore, they
receive a variety of information to support their children. Parents’ discussions about the
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information they receive about their importance demonstrates one of the overarching findings of
the analysis. This theme rises above all others: because parents are important to their children’s
development of language skills, they receive information about what to do with their children
during common activities and routines, and talking frequently with their children is key to this.
For example, when asked about their role in promoting their child’s language development,
parents said things like: “We’re language models. He’s gonna learn what he sees, and now what
he hears” (105) and “Parent interaction. Because [the service providers] only get to see him an
hour a week, and for him to really make progress there needs to be more than just an hour
interaction per week.” (101).
This next quote also demonstrates the overarching interconnectedness—parents receive
information about engaging in different activities together and communicating during these
times, and that they are important to their child’s language development, yet they still long for
more:
[What they’ve told me], you know, I mean that’s kind of what I would do anyway. So far
we haven’t implemented anything special. […] I’m a first time mom, so I know normal
things like read and play and puzzles, and you know, I know kind of the basics. But if
there’s something specific or special I should be doing with her—I keep telling them,
‘Let me know,’ and they keep saying that, ‘Right now, just what you’re doing is what
you do. You play, you read, you talk. You describe what you’re doing as you’re doing it’
[…] I’m waiting for that [additional] instruction and I haven’t got it, and that might be,
it’s not a criticism. That might be my only question, about like: ‘Is there more?’ They
don’t seem to think so. […] They’re focused on me, on her, on us. Yeah, they’re very
concerned, they’re very caring, so that’s awesome. I just can’t wait till we start
implementing specific things. (111)
Summary
The patterns in the information parents received from their service providers demonstrate
that parents receive information that they are the primary change agent for their child—they are
important, and their importance goes above and beyond what the service provider can do in the

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short amount of time that they see the family. Further, parents receive information about how to
increase the amount of language their children are exposed to, as well as specific information
about the importance of focusing on sounds and incorporating additional channels of
communication. Since the parent, and the child’s family as a whole, is particularly important to
this process, these suggestions are about routines or activities that are part of their everyday life
with their child. Despite receiving a variety of suggestions, it is clear that parents have a strong
desire for additional, specific information—their child is not the same as children who are
typically developing or have other types of disabilities. Parents’ need their interests or choices
related to the use of signs or sign language to be better supported, and they feel that this can be
done by receiving with additional information about the use of signs or sign language.
Furthermore, since they are the most important individual in their child’s life and their child has
unique needs, they feel as if there must be more nuanced ways in which they should be
communicating or interacting with their child in order to best promote language development.
Discussion
The purpose of this study was to investigate parents’ accounts of the information they
receive about how to promote the language development of their children with hearing loss,
based on their interactions with early intervention service providers. The findings of this study
demonstrate that some of the information that parents receive is in line with both research and
best practices in the field of early intervention overall, as well as those related to children with
hearing loss. However, the findings also demonstrate that there is considerable room for
improvement in order for families to feel fully supported in their efforts to support their
children’s language development.

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Alignment with Best Practices
An overarching result of this study is that parents are provided with information about
their importance to their child’s language development—parents are told that they are “key” and
because of their relationship with their child, including the amount of time they spend with their
child in comparison to the service provider, that they and their family are the most important
individuals who can positively support their children’s language development. This finding is in
line with recommendations for family-focused early intervention, given that one of the
foundations is supporting parental self-efficacy (Division for Early Childhood, 2014; Moeller et
al., 2013; Workgroup on Principles and Practices in Natural Environments, 2008). In addition,
parents’ reports of suggestions that focus on the idea of frequently communicating about things
that are already part of their everyday lives is also in line with best practices. It is important that
parents receive information that can be easily integrated into their everyday lives and interactions
with their children (Dempsey & Keen, 2008; Marschark, 2007; Moeller et al., 2013).
Furthermore, the central theme of this study relates to parents’ receipt of information
about the importance of their constant communication with their child. This emphasis on
frequently talking represents one key piece to promoting the language development of children
with hearing loss—certain quantities of parents’ language are shown to be supportive of the
language development of children with hearing loss (DesJardin & Eisenberg, 2007; Cruz et al.,
2013; VanDam, et al., 2012; Ambrose et al., 2014). However, it is not the only aspect of parents’
communication, or modality, that should be considered or encouraged by service providers. The
parents in this study did receive additional information above and beyond the emphasis on
quantity; some of the suggestions parents were given did relate to qualities of their
communication as well. For example, parents received information about the importance of

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focusing on sounds and using other channels of communication, particularly so that they could
attain a joint focus of attention with their child. This aligns with the importance of parallel talk or
symbol-infused joint attention (i.e., communication about what both a parent and child are
attending to), which have been shown to promote the language development of children with
hearing loss (e.g., Barker et al., 2009; Lederberg & Prezbindowski, 2000).
Unmet Needs
The findings of this study suggest that there are specific ways that parents could be better
supported via the information provided to them by service providers. This includes information
about a) modes of communication that could be used with their child, and subsequent support
based on these decisions, b) communication, in any modality, rather than only spoken language,
and c) the need for more specified information that goes above and beyond overall quantity of
language to include specific quantities and qualities that are particularly important for children
with hearing loss.
Parents discussed their desire to receive additional information or support about the use
of signs or sign language, or their frustrations from not receiving this; parents mentioned that
they need more information and instruction about how to learn signs and sign language, as well
as a more supportive, unbiased environment in which to receive information about the method(s)
of communication they have chosen for their child. Part of providing family-based early
intervention means respecting parents’ goals for their children and providing unbiased
information to families so that they can make informed decisions (Division for Early Childhood,
2014; Workgroup on Principles and Practices in Natural Environments, 2008), including those
related to the mode(s) of communication they will use with their child (Yoshinaga-Itano, 2014;
Moeller et al., 2013).

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Parents reported that they receive information about the use of signs, but this is primarily
at an introductory level, such as the receipt of handouts or websites that show individual signs.
Providing parents with this information only at the introductory level is not satisfactory, and is
not in line with best practices; parents should be provided with in-depth information about the
use of possible modes of communication, including spoken language, signed language, or both,
or any other option within the continuum of choices (JCIH, 2007; Yoshinaga-Itano, 2014;
Moeller et al., 2013). When parents have a desire to learn American Sign Language, these
services need to be provided by early intervention service providers who are fluent or native
signers and have specialized training related to teaching parents these skills (Yoshinaga-Itano,
2014). Providing parents with information about individual pieces of American Sign Language
(e.g., individual signs) is not sufficient, since this only represents a small portion of the language
itself. This study suggests that parents do not receive adequate, appropriate, or complete
information about the use of signs or a sign language, which is consistent with previous research
(Kelly, 2011), but inconsistent with best practices.
In addition, adult learning styles should be taken into consideration (Moeller et al., 2013).
Providing parents with handouts or websites to learn a language is not in line with adult learning
styles, since it does not provide opportunities to practice and receive feedback (Ambrose,
Bridges, & Lovett, 2010). These types of resources also do not align with the way in which this
language could be best learned, given that it uses visual information from hand, body, and
mouth/facial movements (Quinto-Pozos, 2011).
The most prominent suggestion or advice that parents discussed was being encouraged to
“Talk and talk and talk and talk!” (104). Parents’ reports of receiving information about frequent
spoken language, rather than frequent communication which could include any modality, is

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concerning. This focus on talking demonstrates a bias for spoken language, or lack of knowledge
and experience with sign language. It is possible that service providers may worry that providing
information and support for the use of sign language may hinder children’s abilities to learn
spoken language, but first and foremost, service providers should respect parents’ decisions
(Moeller et al., 2013; Yoshinaga-Itano, 2014). Furthermore, research shows that children’s use of
sign language supports spoken language skills (Preisler, Tvingstedt, & Ahlstrom, 2002;
Yoshinaga-Itano & Sedey, 1998); therefore, providing parents with information about both
modalities of language is appropriate, and does not come at the cost of hindering language
development overall. Parents need to be supported by professionals who have specific training
and experiences related to working with children who have hearing loss and their families, who
can then support parents’ interactions with their children regardless of the modality that parents
prefer (Yoshinaga-Itano, 2014; Moeller et al., 2013).
Furthermore, this vague suggestion to talk frequently does not capture each important
aspect of the quantities of parents’ communication: total number words/concepts (tokens), total
number of different words/concepts, or richness, of their language (types), mean length of
utterance, or conversational turns with their children. Instead, this suggestion of talking
frequently seems to suggest that only the total number of word tokens parents use is most
important, even though the richness of parents’ language, their mean length of utterance, and
conversational turns are quantities of their communication that are predictive of language
development for children with hearing loss (Cruz et al., 2013; DesJardin & Eisenberg, 2007;
VanDam, et al., 2012; Ambrose et al., 2014). It also does not capture the qualities that
characterize high-quality communication for children who have hearing loss, such as the use of
higher-level language techniques that are primarily dependent upon responding to children’s

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vocalizations, actions, or interests (e.g., Cruz et al., 2013; DesJardin et al., 2014; DesJardin &
Eisenberg, 2007; DesJardin, 2006). It is possible that parents who receive information about
talking frequently use a large quantity of total words with their children, but this message may
not influence the diversity, or richness, of their language, nor the other qualities of
communication found to be important for children with hearing loss.
Also, while parents do report receiving a variety of information about ways in which they
can support their child’s language development, they also discuss that they need additional, more
specific information about communicating and interacting with their child. Parents discussed that
their children are unique because of their hearing loss; therefore, parents discussed the need to
receive specialized information about how to support their children’s unique needs, and they do
not feel that they are receiving this. This lack of specialized, more nuanced information related to
supporting their children who have hearing loss leads them to feel lost, and that the information
they receive is not sufficient to fully support their attempts to promote their children’s language
development. This need for additional, specific information is line with previous research (Roush
& Harrison, 2002; Fitzpatrick et al., 2008).
Importantly, these particular findings reflect the way in which resources for service
providers are written, since these include vague statements regarding how service providers
should promote parents to create a language-rich environment and use specific qualities of
communication (e.g., JCIH, 2007; Moeller et al., 2013; Yoshinaga-Itano, 2014). It is possible
that these materials are either not being utilized by service providers or are not written in a way
that easily leads to translating the research findings into specific practices by individuals in the
field of early intervention. Overall, there is a lack of specific, identifiable information in the
resources that are intended to guide the information service providers give to parents, and this

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shows up in the gaps that parents identify in the information that they receive. Parents need more
nuanced, specific information that relates to their children’s hearing loss in order to feel more
confident in the information they receive and more skilled in their abilities to promote their
children’s language development.
Implications for Practice
Using the lens of social constructionism, the first step in internalization of information,
which then influences parents’ actions, is through the information they receive from their service
providers. The findings of this study suggest that the information parents receive via their
interactions with early intervention service providers may be integrated into parents’ knowledge
about ways in which they can support their children’s language development. Findings from this
study suggest that parents receive information about the importance of frequently talking, which
is one aspect of parents’ language known to be important for children; however, first and
foremost, this demonstrates that there is a need for service providers to discuss frequent
communication in any modality, rather than focus only on spoken language. Furthermore, this
also demonstrates a need for service providers to shift the emphasis of quantities of
communication, or total number of words/concepts used, to include specific types of quantities
(i.e., richness of language, MLU, and conversational turns) as well as specific types of qualities
(i.e., language about children’s focus of attention or actions or that responds to children’s
language, i.e., techniques such as parallel talk, expansion, recast, open-ended questions); doing
so would yield a more holistic, yet nuanced, view of how parents can promote their children’s
language development.
This need for a more nuanced approach to supporting the language development of
children with hearing loss was evident in parents’ interviews. These shifts in the information that

72

should be provided to parents, away from only the overall quantity of spoken language to more
nuanced aspects of communication in any modality, may help meet these needs that parents
discussed. This is also necessary given that parents in this study receive information about their
importance and that they have the ability to positively influence their children, yet they feel that
they are not provided with specific information about ways in which to support the unique needs
with which their children were born. Therefore, this further demonstrates the need for service
providers to support parents by providing them with additional, nuanced information about
specific quantities and qualities of language, regardless of modality, that are known to be highly
influential for children with hearing loss.
Parents in this study also discussed a need for additional information about the use of
sign language; they need information that would help them to support their child via the use of
sign language alone or in combination with spoken English. This demonstrates a need not only
for support, but also respect for parents’ choices regarding the mode(s) of communication they
use with their child; these choices should be supported in an unbiased way, regardless of the
beliefs of the service provider (Moeller et al., 2013). This also demonstrates that parents should
have a service provider on their children’s early intervention team who is fluent in the use of
American Sign Language, or a sign system of their choice, and has proper training to help
parents acquire these language skills, if this aligns with their interests or choices (YoshinagaItano, 2014); parents need to be provided with more thorough information and unbiased,
unconditional support for their communication choices as long as this means that the child will
have access to a complete language system.
Given that children with hearing loss are part of a low-incidence population, their early
intervention service providers may come from a variety of educational backgrounds;

73

furthermore, there may be an inadequate number of early intervention service providers who
have specialized training related to working with children with hearing loss in order to meet the
needs of these children’s families (see Yoshinaga-Itano, 2014). With this in mind, as well as the
findings of this study that demonstrate that parents need to receive more nuanced and unbiased
information, early intervention service providers working with families who have children with
hearing loss may need additional training and support. The pre-service and ongoing training for
these service providers should focus on an understanding that the use of sign language, alone or
in combination with spoken language, will not impede the language development of children
with hearing loss and that providing unbiased information about communication options is an
essential aspect of early intervention for these families.
Limitations
Specific limitations of the current study include that the majority of participants were
highly educated and reported high levels of household income. Therefore, the results of this
study likely do not represent the experiences of families of lower socioeconomic status,
including those with lower levels of education. In addition, all families were Caucasian, meaning
that the experiences of more diverse families are also not represented in these data. Furthermore,
the majority of families in this study indicated that their method of communication with their
child was primarily spoken language and all children, with the exception of one child who had
mild hearing loss in only one ear, were using hearing aids or cochlear implants—this likely
influenced some of the findings of this study, such as parents’ receipt of information about the
importance of focusing on sounds. Also, the inclusion of families only within the state of
Michigan, which has different eligibility criteria and provision of services for children who may
be eligible for early intervention services only but not special education (Michigan Association

74

of Administrators of Special Education, 2014), mean that the results may only relate to the early
intervention services provided within this limited geographical area.
There are additional limitations related to the study design; in particular, this study is not
a direct measure of the information that parents are provided with via early intervention, but
rather their memory and potential internalization of this information. Therefore, this study may
have elicited only parents’ reports of the most salient information that they received, and is
interpreted through the lens of parents’ perceptions and overall experiences of early intervention
services. In addition, a few parents in this study discussed the information that is received by
their child’s nanny, who was the one present during certain early intervention visits. Considering
all of these factors, it is likely that the information provided to families as part of early
intervention includes themes that did not emerge from the data in this study, since it is not
expected that parents will remember or internalize all of the information provided to them. This
does, however, lead to questions about the alignment, as well as disconnections, between
information that parents internalize versus that which service providers may intend or believe
that they are providing to parents. It is possible that there are certain messages service providers
intend for parents, but that are not made explicit. For example, observation of early intervention
interactions, particularly those that are home-based, may show that service providers interact
with the child and/or parent primarily through play-based activities, even though they may never
explicitly recommend that parents play with their children.
Future Directions
Future research should investigate the relationship between best practices that are
suggested in the resources intended for service providers, and service providers’ own goals for
the information that they give to parents since this may influence information or suggestions they

75

provide to parents. In addition, observational measures of early intervention—not only of
information provided to parents, but also the way in which this information is provided (e.g.,
verbally, via handouts, demonstrations, opportunities for parents to practice, etc.)—should also
be considered in order to more accurately measure the relationship between best practices and
the actual practices of service providers; observational studies would also provide more insight
to the relationships between actual practices, parents’ internalization of information and,
subsequently, their ways of interacting with their children. For example, future research should
investigate the relationship between the information parents receive and the actual quantities and
qualities of their communication with their children to better understand how the information
that parents receive may influence aspects of parent’s communication that have been shown to
predict the language skills of children with hearing loss. In addition, parents’ learning styles and
preferences for receiving information should also be studied to better understand individual
differences and how to best support families.

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CHAPTER 3: STUDY 2
Abstract
Specific quantities and qualities of parents’ language are predictive of the language skills
of children with hearing loss, such as parents’ use of a greater amount of different words (e.g.,
word types) and certain language techniques (e.g., expansion). Researchers have hypothesized
that information parents receive as part of early intervention services may influence both the
quantities and qualities of parents’ language input; however, this has never been investigated.
This study examined parents’ (N = 12) quantities of language and use of specific language
techniques during play with their children who were between 12-29 months of age (M= 21.6),
and how this related to their reports of information received from their service providers about
how to promote the language development of their children with hearing loss. Relationships
between these aspects of parents’ communication and other important contextual factors, family
socioeconomic status and children’s current language skills, were also examined. There was
substantial variation in the quantities of parents’ language, including overall talkativeness, and in
their use of specific language techniques. Parents’ use of parallel talk was related to their receipt
of information about the importance of frequently talking with their children during daily
routines. Other patterns indicated that parents of lower socioeconomic status used more
directives with their children, and parents whose children used a greater number of word types
may elicit parents’ use of the language techniques shown to promote their language
development.

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Introduction
Children with hearing loss frequently have lower language skills compared to their
hearing peers (Niparko et al., 2010; Barker et al., 2009; Moeller, 2000; Yoshinaga-Itano, Sedey,
Coulter, & Mehl, 1998). There are a number of protective factors for the language development
of these children, including the ages at which they are identified with hearing loss (YoshinagaItano et al., 1998; Yoshinaga-Itano, 2003; White & White, 1987; Apuzzo & Yoshinaga-Itano,
1995; Robinshaw, 1997), begin early intervention (Moeller, 2000; Yoshinaga-Itano, 2003; Vohr
et al., 2008; also see Leigh, Newall, & Newall, 2010 for a review), and begin using a hearing
device, such as a hearing aid or cochlear implant (Niparko et al., 2010; Dettman, Pinder, Briggs,
Dowell, & Leigh, 2007; Yoshinaga-Itano et al., 1998). However, even when these factors are
considered, there is still great variability in these children’s language skills (Niparko et al., 2010;
Barker et al., 2009; Moeller, 2000; Yoshinaga et al., 1998). Other important aspects of these
children’s lives that explain some of this variability are features of their interactions with their
parents, including specific quantities and qualities of their parents’ language use during parentchild interactions (Moeller, 2000; Calderon, 2000; DesJardin, 2006; DesJardin & Eisenberg,
2007; Cruz, Quittner, Marker, DesJardin, & CDaCI Investigative Team, 2013; VanDam,
Ambrose, & Moeller, 2012; Ambrose, VanDam, & Moeller, 2014; DesJardin et al., 2014). An
implication from research is that these aspects of parents’ language may be influenced by the
information parents receive from their early intervention service providers (DesJardin, 2006;
DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam, et al., 2012; Ambrose et al., 2014), or
specific contextual factors in the lives of these children or families, such as socioeconomic status
(Niparko et al., 2010; Barker et al., 2009; Geers, Moog, Biedenstein, Brenner, & Hayes, 2009;

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Szagun & Stumper, 2012; Cruz et al., 2013) or children’s current language skills (Farran,
Lederberg, & Jackson, 2009; Lederberg & Prezbindowski, 2000; Cruz et al., 2013).
Parent-Child Interactions and Children’s Language Development
According to Tomasello (2008), the process by which children develop language is
through collaborative interaction with others; meaningful social interactions and children’s
desires to inform, request, or share information are the foundation for their language
development. For this reason, it is important that parents’ language inputs focus on children’s
interests or actions; it is in these instances of joint attention that parents’ language inputs are
most influential (e.g., Tamis-LeMonda, Bornstein, & Baumwell, 2001; Lederberg &
Prezbindowski, 2000). Therefore, the importance of these social interactions for children’s
language development, and the fact that children’s parents are typically the most consistent and
stable individuals with whom they interact, the importance of parent-child interactions early in a
child’s life cannot be underestimated (e.g., Dempsey & Keen, 2008; Marschark, 2007; Moeller et
al., 2013).
An important component of family-centered early intervention for children with hearing
loss is that service providers promote aspects of parent-child interaction known to be supportive
of children’s language development, such as providing children with language-rich
environments, parental responsivity and sensitivity toward the child, and promoting parents’ use
of certain language techniques (Moeller et al., 2013; Yoshinaga-Itano, 2014; JCIH, 2007). These
best practices are both informed and validated by research that shows specific aspects of parentchild communication influence children’s language development. In particular, specific
quantities (e.g., amount) and qualities (e.g., responsiveness, language techniques) of parents’
language with children who have hearing loss are known to be influential to children’s receptive

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and expressive language skills (Cruz et al., 2013; DesJardin et al., 2014; DesJardin, 2006;
DesJardin & Eisenberg, 2007).
Research related to parents’ communication with both typically developing children, as
well as those with disabilities, suggests that higher quantities of parent language positively relate
to children’s language outcomes (e.g., Hart & Risley, 1995; Huttenlocher, Haight, Bryk, Seltzer,
Lyons, 1991; Cruz et al., 2013; DesJardin & Eisenberg, 2007). The specific quantities that have
been shown to be most beneficial to the language development of children with hearing loss
include parents’ mean length of utterance (MLU), number of different words used (word types),
and conversational turns (Cruz et al., 2013; Szagun & Stumper, 2012; DesJardin & Eisenberg,
2007; VanDam et al., 2012; Ambrose et al., 2014). Therefore, it is not simply that more language
exposure is better for children with hearing loss (e.g., word tokens), but instead, what is most
beneficial is more of specific aspects of parents’ language.
Specific quantities of parents’ language are important; however, the qualities of parents’
language while interacting with their children are also highly influential. For instance, the ways
in which parents interact with their infants, such as their responsiveness or sensitivity, predicts
many developmental outcomes, including language (Pressman, Pipp-Siegel, Yoshinaga-Itano,
Kubicek, & Emde, 1998; Pressman, Pipp-Siegel, Yoshinaga-Itano, & Deas, 1999; also see
Lederberg & Prezbindowski, 2000). It is parents’ communication with their children within these
sensitive or responsive interactions that is important to children’s language development. For
example, parents’ language that is responsive to what it is that children are doing or attending to
predicts children’s vocabulary development, yet when parents’ language focuses on something
outside of their children’s focus of attention, this is not influential to children’s language
development (Tomasello & Farrar, 1986; Hoff-Ginsberg, 1987).

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Aspects of parents’ sensitivity and their communication within these sensitive
interactions are known to be particularly important for children whose language skills are not as
advanced. For example, when mothers change their verbal behavior based on a change in their
child’s vocalization or interest, this is predictive of children’s receptive language skills, and the
effect is strongest for children whose language skills are not as advanced (Baumwell, TamisLeMonda, & Bornstein, 1997). This is consistent with the effects of maternal emotional
availability, which included mothers’ sensitivity; when comparing hearing mothers’ interactions
with a typically hearing child to hearing mothers’ interactions with a child with hearing loss,
both sets of dyads had similar rates of maternal emotional availability, yet this availability had a
significantly larger effect on children’s language growth for children with hearing loss (Pressman
et al., 1998). Thus, parents’ sensitivity to their children and their communicative responses
within those interactions are extremely important for the language development of children who
may struggle to develop age-appropriate language skills.
These aspects of parental sensitivity are similar to another aspect of parent-child
interaction: parents’ use of certain language techniques that include aspects of responsiveness.
For example, qualities of parents’ language that have been linked to children’s expressive and
receptive language skills include parents’ use of language techniques that include responses to
children’s vocalizations or discussions of what it is that their children are interested in or doing
(Tamis-LeMonda et al., 2001; Girolametto, Weitzman, Wiigs, & Pearce, 1999; McNeil &
Fowler, 1999; Yoder, McCathren, Warren, & Watson, 2001; Dale, Crain-Thoreson, NotariSyverson, & Cole, 1996; Cruz et al., 2013; DesJardin et al., 2014; DesJardin, 2006; DesJardin &
Eisenberg, 2007). Parents’ language techniques that are known to be important for the language
development of children with hearing loss or those who experience language delays include

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parents’ use of parallel talk (a verbalization that relates to what the child is doing or attending to)
and expansion (expanding upon children’s language by adding words to make it a complete
sentence or thought); these are considered higher-level language techniques since these are
shown to positively influence language development (Cruz et al., 2013; Szagun & Stumper,
2012; McNeil & Fowler, 1999; Girolametto et al., 1999; Dale et al., 1996). In addition, other
higher-level language techniques include parents’ use of recast, which includes repeating the
child’s communication in the form of a question, and open-ended questions, which can be a
phrase or a question that would require more than a one-word response (Cruz et al., 2013;
DesJardin, 2006; DesJardin & Eisenberg, 2007; Girolametto et al., 1999; Fung, Chow, &
McBride-Chang, 2005; McNeil & Fowler, 1999; Dale et al., 1996). Language techniques that
have been shown to be detrimental to the language development of children with hearing loss
include directives, when parents tell the child to do something or give the child directions, or
techniques that include talking to the child about something even if the child is not paying
attention (DesJardin, 2006; DesJardin & Eisenberg, 2007). Those that are shown to neither help
nor harm the language development of children with hearing loss include making comments that
acknowledge what the child has said or done (e.g., “Ok,” “Good job!”) or imitating the child’s
exact utterance (DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013). Therefore,
lower-level techniques are those that either do not influence the language development of
children with hearing loss, or are detrimental (e.g., DesJardin, 2006).
The difference between higher- and lower-level techniques and the influence they have
on the language development of children with hearing loss suggests that parents’ use of these
higher-level language techniques provides children with greater access to complex language and
more opportunities to engage in the language environment, while lower-level techniques may

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stifle this (Cruz et al., 2013). Importantly, of the studies that have investigated parents’ use of
these language techniques with children who have hearing loss, only one has focused on infants
and toddlers children who have hearing loss (Cruz et al., 2013), despite the fact that this is a
critical period for language development (Centers for Disease Control, 2015) and parent-child
communication is crucial to this process (Moeller et al., 2013). Therefore, an aim of the current
study is to examine the quantities and qualities of parents’ language inputs when they interact
with their infants and toddlers who have hearing loss.
Knowing that specific quantities and qualities of parents’ language inputs predict the
language skills of children with hearing loss, this leads to questions about what may influence
these aspects of parents’ language, especially during this critical time for children’s language
development. There are a few different aspects of these parents’ and children’s lives that should
be taken into consideration, such as the information parents of children with hearing loss receive
about how to promote their children’s language development and their role in this process, the
family’s socioeconomic status, and natural adaptations parents may make based on their
children’s language skills.
The potential relationship between information provided to parents and aspects of
their language inputs. Parents of children with hearing loss use significantly more lower-level
language techniques with their children compared to parents of typically developing children
when these children’s language ages are matched (DesJardin et al., 2014). Furthermore, these
same parents use significantly more lower-level language techniques when their children have
below average language skills, but there is no difference in their use of higher-level language
techniques based on whether their children have below average or average/above average
language skills (DesJardin et al., 2014). This suggests that parents of children with hearing loss

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may need support in order to shift the qualities of their language over time in ways that are
dependent upon the child’s growing skills (DesJardin et al., 2014), yet we know very little about
the information provided to families during the period that children may be transitioning between
stages of language development.
One of the goals of family-focused early intervention is to promote children’s language
development by increasing positive parent-child interactions and supporting parents to provide
language-rich environments (Division for Early Childhood, 2014a; Dempsey & Keen, 2008;
Moeller et al., 2013; Spencer & Marschark, 2010; Marschark, 2007; JCIH, 2007; YoshinagaItano, 2014). Resources that are intended for service providers or parents indicate that the
information parents receive about their interactions with their children, including their language
input, is critical to their children’s outcomes (Marschark, 2007; Yoshinaga-Itano, 2014; Division
for Early Childhood, 2014b). This is in line with the theory of social constructionism, given that
it postulates that our knowledge is influenced by our communication with others (Gergen, 1985;
Lock & Strong, 2010) and then influences our actions (Burr, 1995), which suggests that aspects
of parents’ linguistic inputs when interacting with their children may be influenced by the
information they receive from their conversations with early intervention service providers. Best
practices also allude to this, given that the purpose of the information provided to parents is to
build on their strengths in order to improve specific aspects of their interactions with their
children, such as their communication (Marschark, 2007; Moeller et al., 2013; Division for Early
Childhood, 2014b), since this is linked to children’s language outcomes (DesJardin, 2006;
DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam, et al., 2012; Ambrose et al., 2014).
When children with hearing loss begin early intervention services relatively early there is
still substantial variability in their language skills (Moeller, 2000), and given that a primary goal

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of early intervention is to support parents to then support their children’s development (Division
for Early Childhood, 2014a; Moeller et al., 2013), this leads to questions about how the
variability of parents’ linguistic inputs may be influenced by the variation in information they
receive from early intervention service providers. For example, although family involvement in
early intervention is beneficial for children with hearing loss (Antia, Jones, Reed, & Kreimeyer,
2009; Moeller et al., 2013; Yoshinaga-Itano, 2014; Moeller, 2000), research with families of
children with hearing loss shows mixed results about how family involvement influences aspects
of parent-child communication. One study found that the more mothers felt that they were
involved in their child’s speech-language development as part of early intervention, the more
they used two specific higher-level language techniques, parallel talk and expansion, and the less
they used certain lower-level language techniques, two of which were detrimental to their
children’s language development (DesJardin & Eisenberg, 2007). Yet, another study found that
mothers’ reported involvement in early intervention activities that were meant to promote
children’s speech-language development was related to the mothers’ use of two lower-level
language techniques, closed-ended questions and imitation (DesJardin, 2006); furthermore,
mothers’ use of closed-ended questions was also related to their reports of their service providers
demonstrating listening and language activities. This implies that when families are more
involved in early intervention services for their children, they may more frequently use
techniques that positively influence their children’s language development (DesJardin &
Eisenberg, 2007) but also those that have no effect (DesJardin, 2006). This leads to questions
about how aspects of parents’ language inputs are influenced by variation in the information
parents receive from service providers (DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz et
al., 2013; VanDam, et al., 2012; Ambrose et al., 2014).

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The foundational studies that have shown the relationship between specific aspects of
parents’ language and the language development of children with hearing loss each mention that
the information parents receive may be part of what explains the variation in their language
inputs (DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam, et al., 2012;
Ambrose et al., 2014); however, none of these studies have investigated the potential
relationships between information that parents receive and aspects of their language when they
interact with their children. Although we know little about these potential relationships, drawing
from other areas of research shows that when parents of children with disabilities are provided
with information, this can lead to changes in their interactions or language with their children.
Importantly, these changes then predict children’s language outcomes (e.g., Fung et al., 2005;
Hauser-Cram et al., 2001; Buschmann et al., 2009; Falkus et al., 2015; for reviews see Roberts &
Kaiser, 2001; Kaiser & Hancock, 2003). Therefore, the primary aim of the current study is to
explore the relationship between the quantities and qualities of parents’ language and how this is
related to the information they have received from their early intervention service providers.
Contextual factors that influence parents’ communication. Other important factors to
consider that may influence aspects of parents’ communication include the family’s
socioeconomic status (SES), and children’s language abilities since these may naturally lead to
parents adjusting their language input. It is well established that a family’s SES, including
income and parental education, is shown to be important predictor of parents’ language use and
subsequently, children’s development, including their language skills (Hart & Risley, 1995;
Rowe, 2008; Hoff, 2003; for reviews see Bornstein & Bradley, 2003; Conger, Conger, & Martin,
2010; Bradley & Corwyn, 2002). These same patterns also hold true for children with hearing
loss; those who are part of higher SES families tend to have better language outcomes (e.g.,

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Niparko et al., 2010; Barker et al., 2009; Geers et al., 2009; Szagun & Stumper, 2012). In
particular, Cruz and colleagues (2013) found that SES influenced parents’ word types used and
children’s expressive and receptive language; however, it did not influence parents’ use of
higher- or lower-level language techniques. This may suggest that all families, regardless of SES,
may use similar rates of specific language techniques, but also that all types of families may
benefit from receiving information about the importance of increasing their use of higher-level
language techniques (Cruz et al., 2013).
Another aspect of the lives of these parents and children that may be an important
contributor to what influences parents’ language input, is that parents may adapt their language
use so that it is most appropriate to children’s current levels of language development; this is
actually a skill that service providers are encouraged to help parents develop (Moeller et al.,
2013). However, the types of adaptations service providers should encourage parents to make
and when to make these adaptations are not discussed in detail within the resources that outline
best practices (e.g., Moeller et al., 2013; Yoshinaga-Itano, 2014). It is possible that adults may
make some adaptations on their own (e.g., Girolametto & Weitzman, 2002; Tamis-LeMonda et
al., 2001; Goldin-Meadow, Goodrich, Sauer, & Iverson, 2007); parents of children with hearing
loss have also been shown to adapt their language strategies based on their child’s current
language skills (e.g., Farran et al., 2009). For example, mothers of children with hearing loss
have been shown to be more directive with their children compared to mothers of children who
have typical hearing; however, when children are matched based on language abilities, rather
than age, there are no differences between the directiveness of mothers who have children with
hearing loss (Lederberg & Prezbindowski, 2000). This suggests that mothers of children with
hearing loss are able to adapt their language strategies based on the child’s language skills.

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The studies that have investigated the quantities and qualities of parents’ language
suggest that their use of specific quantities (e.g., word types, MLU, and conversational turns) and
of higher-level language techniques explain a portion of the variability in children’s language
skills. However, in most of these studies, directionality cannot be assumed (e.g., DesJardin,
2006; DesJardin & Eisenberg, 2007; DesJardin et al., 2014). For example, the relationship
between parents’ use of higher-level language techniques and children’s language skills is
possibly driven by children’s growing language skills, such that when children have better
receptive or expressive language, they elicit parents’ use of higher-level language techniques. Or,
when children’s language skills are lower or below average, parents may naturally use lowerlevel language techniques. The one study to date that has tested the bidirectional nature of this
relationship between parents’ language use and children’s language skills showed that children’s
expressive language skills prior to receiving cochlear implants, when they were just under 16
months of age on average, predicted the number of different words their parents used as well as
parents’ use of higher-level language techniques, such that children with better expressive
language skills elicited certain aspects of parents’ language input; this was true for dyads 12
months after implantation, but this relationship did not remain significant 24 and 36 months after
implantation (Cruz et al., 2013). This suggests that parents may be particularly sensitive to their
children’s earliest language skills, and these skills may elicit specific aspects of parents’
language. Parents of children with hearing loss whose language skills are greater may use more
higher-level language techniques compared to parents of children whose language skills are not
as good, since these higher-level language techniques may be best suited for children whose
language skills are more advanced (e.g., McNeil & Fowler, 1999; Dale et al., 1996).

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In sum, although research suggests that it is parents’ use of specific quantities or qualities
that can positively predict the language development of children with hearing loss, there is also
reason to believe parents’ language inputs are related to their SES or that parents of children with
hearing loss may adjust their language inputs based on the child’s skills. Therefore, additional
aims of this study address how parental SES and children’s language skills may relate to the
quantities and qualities of parents’ language when they interact with their children who have
hearing loss.
Current Study
Both the quantities and qualities of parents’ communication are powerful factors that
explain variability in both expressive and receptive language skills of children with hearing loss.
Only limited research has described specific quantities and qualities of parents’ communication
with their infants and toddlers with hearing loss (e.g., Cruz et al., 2013), despite the importance
of involving these children in early intervention from very young ages (Moeller, 2000;
Yoshinaga-Itano, 2003; Vohr et al., 2008) and of focusing on parents as central to intervention
(Division for Early Childhood, 2014a; Dunst, Trivette, & Hamby, 2007; Moeller et al., 2013;
Marschark, 2007). Therefore, the first aim of this study is to investigate the variation in the
quantities and qualities of parents’ communication with their infants and toddlers who have
hearing loss.
Furthermore, service providers are encouraged to help parents create positive parent-child
interactions and language environments, which includes providing them with information about
how to strengthen their interactions with their children (Division for Early Childhood, 2014b;
Moeller et al., 2013; Yoshinaga-Itano, 2014; JCIH, 2007; Alexander Graham Bell Association
for the Deaf and Hard of Hearing, 2013). In line with the theory of social constructionism and

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implications of past research, there is reason to believe that the aspects of parents’
communication that have the potential to positively influence the language development of
children with hearing loss are influenced by the information parents receive from their early
intervention service providers (Gergen, 1985; Lock & Strong, 2010; Burr, 1995; DesJardin,
2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam et al., 2012; Ambrose et al.,
2014). However, little is known about the relationship between parents’ language inputs and
information they receive since no studies have examined this. For this reason, the second aim of
this study is to explore the potential relationships between the information parents report
receiving from early intervention service providers and their use of specific quantities and
qualities of language that could promote their children’s language development; identifying these
relationships could elucidate the types of information that parents internalize from their early
intervention service providers that relate to parents’ language inputs that are particularly
important to the language development of children with hearing loss, or those that are shown to
be detrimental.
Lastly, although it is important to examine the relationships between aspects of parents’
communication and the information they receive from early intervention service providers, other
contextual factors of these families must not be ignored. In particular, research shows that
families’ SES influences children’s language outcomes, such that children who come from
families who have higher incomes or levels of parental education are likely to be exposed to the
quantities and qualities of parental language that are shown to be important (Hart & Risley,
1995; Rowe, 2008; Hoff, 2003; Niparko et al., 2010; Cruz et al., 2013). In addition, it is also
possible that parents are intuitively adjusting their language based on the child’s language skills
in order to better match the child’s current level of development (Farran, Lederberg, & Jackson,

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2009; Lederberg & Prezbindowski, 2000). Therefore, the third aim of this study is to explore
patterns between the variations in parents’ language and how these may also be influenced by
contextual characteristics that are frequently influential, specifically, the family’s socioeconomic
status and children’s current language skills.
Method
Participants
Twelve parent-child dyads participated in this study; participants included 11 mothers
and 1 father, and their children who had permanent hearing loss who were between 12-19
months of age (M = 21.6 months). Families were all participating in home-based early
intervention services under Part C of the Individuals with Disabilities Education Act, and had
been receiving these services for 15.4 months on average at the time of the home visit (SD =
7.8). Children’s degree of hearing loss varied, and 11 children had bilateral hearing loss. Eight
children were using bilateral hearing aids and 3 were using bilateral cochlear implants, and the
child who had mild, unilateral loss was not using any type of hearing assistance; children were
12.2 months of age on average when they began using their hearing devices. Children were 3.6
months of age on average when they were identified with hearing loss (SD = 4.1) and 6.7 months
when they began receiving early intervention services (SD = 6.4). Additional demographic
information for parents, children, and families are included in Table 3.1.

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Table 3.1
Demographic Information
Variable
Parent demographics (%)
Gender of participant
Mother
Father
Employment status
Stay-at-home parent
Working part time
Working full time
Education level
High school or GED
Some college
Associate’s degree
Bachelor’s degree
Master’s degree
Professional or doctorate degree
Child demographics
Gender
Female
Male
Age of child when identified with hearing loss (months, SD)
Age of child when he/she first began receiving early intervention
services (months, SD)
Amount of time child has been receiving any type of intervention
services (months, SD)
Age of child at time of visit (months, SD)
Hearing loss
One ear
Both ears
Level of hearing loss in best ear when unaided
Mild (27 to 40 dB hearing loss)
Moderate (41 to 55 dB hearing loss)
Moderately Severe (56 to 70 dB hearing loss)
Profound (90+ dB hearing loss)
Use of hearing devices
Hearing aids for both ears
Cochlear implants for both ears
None
Family demographics
Household income before taxes
$12,000-19,999
$40,000-59,999
$80,000 or more
Race and Ethnicity*
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(N = 12)

91.7% (11)
8.3% (1)
33.3% (4)
33.3% (4)
33.3% (4)
16.7% (2)
25.0% (3)
8.3% (1)
16.7% (2)
16.7% (2)
16.7% (2)

58.3% (7)
41.7% (5)
3.6 (4.1)
6.7 (6.4)
15.4 (7.8)
21.6 (6.0)
8.3% (1)
91.7% (11)
33.3% (4)
16.7% (2)
16.7% (2)
33.3% (4)
66.7% (8)
25.0% (3)
8.3% (1)

25.0% (3)
16.7% (2)
58.3% (7)

Table 3.1 (cont’d)
White, non Hispanic/Latino
91.7% (11)
White, Hispanic/Latino
8.3% (1)
Parents’ reports of the mode of communication they and their child
use together
Spoken only
8.3% (1)
Mostly spoken, with minimal signing
41.7% (5)
More spoken, some signing
41.7% (5)
Spoken and signing equally
8.3% (1)
*Parents reported their own race and ethnicity and then separately answered the same
question for their child in order to consider whether the race or ethnicity of the child’s
other parent differed from that of the participating parent’s. In this study, the participating
parent and the child’s race and ethnicity did not differ.
Recruitment and Procedure
Information about this study was primarily distributed to families by county coordinators
and service providers in the state of Michigan who provide Part C early intervention services
under the Individuals with Disabilities Education Act; in the state of Michigan, this is called the
Early On system (Michigan Department of Education, 2013). Information about this study was
also distributed via social media networks and events for families in Michigan who have children
with hearing loss. Inclusion criteria for children included that they must be between 12 and 30
months of age, enrolled in early intervention services, and have no additional disability or delay
that influences their cognitive abilities. Families had to be using English as their primary
language, and although only one parent participated in the study, both parents had to have typical
hearing abilities. This study focused on typically hearing parents since research has shown that
there are differences in the ways in which hearing parents interact with their children who have
hearing loss, as compared to parents who have hearing loss; importantly, children with hearing
loss who have parents with typical hearing face the greatest risk for delays in their language
skills, possibly due to aspects of parent-child communication that are more challenging when
there is a mismatch in hearing statuses (Meadow-Orlans, 1997; Meadow-Orlans & Spencer,

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1996; Spencer, Erting, & Marschark, 2000). Children could have any degree of hearing loss, and
families could be using any form of communication with their children (e.g., signed, spoken, or a
combination of both).
When a parent contacted the research team and the family was deemed eligible to
participate, a home visit was scheduled at a time that worked best for the parent and child. Prior
to the home visit, a packet was sent to the parent to fill out which included questions about the
child’s and family’s demographic characteristics and participation in early intervention services.
The home visit began by providing parents with information about the study, as well as their
rights as a participant, and their ability to skip any part of the visit or stop participating at any
time; this process followed the Institutional Review Board procedures of Michigan State
University. Home visits included a semi-structured interview. Home visits included an
observation of parents and children interacting together, as well as an interview with the parent;
these visits took approximately two and a half hours. Parents received a $40 gift card and
children received a book for participating.
Observation of parent-child free play. To facilitate free play, parents were provided
with the following items: blocks, a puzzle, stacking rings, a doll and bottle, fake food, toy cars,
and plastic animals. Parents were asked to play with their child like they typically would at home
if they had free time. This was video recorded. Portions of the video when the children were
upset or wandered off camera were removed. Videos were standardized to be 10 minutes.
Parent interview. Parents were interviewed about their experiences with the early
intervention services they had received. The total interview was approximately 60 minutes long
and included sections on parents’ feelings about how early intervention was going and how they
felt about their children’s progress, information they have received from their service providers,

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and ways in which they thought early intervention could be improved. The portions of the
interviews used for the current study include questions about information parents had received
from service providers about how to interact with their child, promote their children’s language
development, and what they have been told about their role in promoting their children’s
language development. These interviews measured parents’ reports of the information they
received, but to be succinct, hereafter this will be referred to as ‘information parents received.’
Transcription and quantitative observational coding of parents’ language
techniques. Parents’ and children’s spoken or signed language, vocalizations, and noises used
during free play were transcribed using the Codes for the Human Analysis of Transcripts
program (CHAT; MacWhinney, 2015); utterances included a) language, b) noises, which
included things like pretend eating, tickling, or animal sounds, and c) vocalizations, which were
usually made by the child (e.g., “bababa”) but also sometimes spontaneously made by or
imitated by the parent. Noises and vocalizations were included since these are important aspects
of the babbling stage of language development and pretend play; they also provide a framework
to understand a child’s general ‘talkativeness’ even before traditional expressive language skills.
The delineation of separate utterances was based on pauses or intonations, the flow of
conversation, or when the parent or child took turns back and forth. Each transcript was double
checked by a second member of the research team. A member of the research team who is a
teacher of the Deaf and fluent in the use of American Sign Language transcribed parents’ and
children’s use of signs and sign language; it should be noted that this accounted for a very small
percentage of parents’ language (see Table 3.3), and nearly all parents used individual signs
rather than American Sign Language. As suggested by the CHAT manual (MacWhinney, 2015),
when parents used signs or sign language without speech, it was transcribed as the word

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concept(s) with the @sl symbol added, and when they were used in combination with speech it
was transcribed with the @sas symbol added to indicate that both sign and speech were used. For
example, if a parent signed “yes, big bear” without speech, it was transcribed as “yes@sl, big@sl
bear@sl” and if a parent used signs while speaking it was transcribed as: “yes@sas, big@sas
bear@sas”.
Transcripts were used to determine a number of different quantities of parents’ and
children’s language. First, the total number of word tokens were counted; each word or sign,
even if it was duplicated multiple times through the transcript, was counted as one token each
time it was used. Word tokens that were simultaneously spoken and signed were counted as one
word token. Second, we counted the total number of different words or signs used (referred to as
word types); for example, if a parent used the word “dog” 10 times, this would count as one
word type. Word tokens were summarized in such a way that if the parent said, signed, or said
and signed a particular word token, it would be considered only one word type. For example, if a
parents’ transcript included these two utterances, “Yes, big bear. He is a big@sas bear@sas.” this
parents’ word tokens would be 8, and their word types would be 6 (big and big@sas are one
word type, and bear and bear@sas are one word type). Lastly, mean length of utterance (MLU)
was calculated by dividing the number of word tokens by the number of utterances.
Transcripts were used to code parents’ use of language techniques (LTs) at the utterance
level, which included spoken or signed language, noises, or vocalizations, using a coding system
comparable to that of other researchers (e.g., DesJardin, 2006; DesJardin & Eisenberg, 2007;
Cruz et al., 2013; DesJardin et al., 2014; see Table 3.2). Utterances could also be coded as
‘other’ if they were unintelligible or the parent’s language was not child-directed, such as
comments to the research team; these were not included in further analyses. Four of the 12

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videos were randomly selected to be double coded. Cohen’s kappa ranged from .75 to .85 (M =
.80), which is considered substantial agreement (Vierra & Garrett, 2005). For the 8 remaining
videos, the primary investigator watched the videos and looked over the coding of each
utterance. The member of the research team who originally coded the videos met with the
primary investigator to discuss each of the videos after they were double coded or checked, and
they then came to an agreement about the coding of each utterance when there had been an initial
disagreement.
After transcripts were coded for parents’ use of LTs, their use of LTs per minute was
calculated as an additional measure of parents’ talkativeness by summing all LTs and dividing by
10 (number of minutes). Parents’ frequency of each individual LT was calculated by dividing the
number of instances each specific LT was used by 10; this allowed for differences between more
and less talkative parents to be more readily observed for their use of each LT.
Table 3.2
Definitions and Examples of Language Techniques Used to Code Parents’ Utterances, Noises, and
Vocalizations
Code Code Name
Definition
Examples
Lower-level language techniques
CQ
Closed-Ended
A question that the child can
MOT: What is this animal called?
Questions
answer with one word or that only -has one specific or expected
MOT: What color is this?
answer.
DR
Directive
Giving directions; telling the
MOT: Try to fit it in there.
child to do something specific.
-MOT:
IM
Imitation
Repeating the child’s vocalization CHI: Baby.
or verbalization; usually this will MOT: Yes, baby.
be an exact imitation, but it can
also include other words, such as
“hmm” or “yeah.”

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Table 3.2 (cont’d)
LM
Linguistic
Mapping

NO

Noise Making
and
Onomatopoeias

PE

Perpendicular
Talk

RA

Responsive
Acknowledgem
ent

Putting the child’s potential
intended message or actions into
words; this relates to when the
child has vocalized, his/her
utterance is unintelligible, or the
parent’s comment relates to what
the child may be intended via
their actions.

Noises that do not represent any
specific, identifiable animal,
object, or action (e.g., tickling or
other playful noises); or, noises
that imitate animals, objects, or
actions (e.g., vroom, beep, meow,
pretend eating).
A verbalization that relates to
something outside of what the
child is involved in or attending
to, such as an object, activity, or
topic of conversation.
A phrase or word that
acknowledges an utterance,
vocalization, or action of the
child; this could also be phrased
as a question.

Higher-level language techniques
EX
Expansion
Expanding upon the child’s
verbalization; this can include
making grammatical corrections
or adding new information to the
child’s verbalization.
OQ
Open-Ended
A question that the child can
Questions
answer with more than one word
or that could have more than one
possible answer; this can also be a
phrase (e.g., “Tell me…”)

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CHI: voc. [child vocalizes while
touching blocks.]
MOT: You found the blocks.
-CHI: 0. [holds out a doll to parent]
MOT: Ok, I’ll hold the doll now.
-CHI: 0. [puts animal on the floor and
turns away.]
MOT: Oh, you’re done with this now.
MOT: [tickling noise while playing
with child]
-MOT: [eating noise while holding
pretend food]

CHI: [playing with the puzzle]
MOT: Oh, there’s a doll too!
-CHI: Apple.
MOT: There’s a bowl of cereal here
too.
MOT: Thank you!
-CHI: [child puts bottle in baby’s
mouth]
MOT: Oh, so nice.
-CHI: [vocalizes]
MOT: Oh yeah?

CHI: Dog.
MOT: Yes, that is the brown dog.

MOT: What should we do next?
-MOT: Tell me about this.

Table 3.2 (cont’d)
PA
Parallel Talk

RE

Recast

A verbalization that relates to
what the child is involved in or
attending to, such as an object,
activity, or topic of conversation.

When a parent changes the
child’s utterance into a question;
this can include one or more
words.

CHI: Bear!
MOT: Yes, he’s furry.
MOT: It’s a big bear.
-CHI: [playing with stacking blocks]
MOT: I see a blue ring, and a yellow
ring.
CHI: More.
MOT: More?
-CHI: Baby.
MOT: What are you going to do with
the baby?

Transcription and coding of parent interviews. This study used thematic analysis to
code parents’ interviews, following the steps outlined by Braun and Clarke (2006). The
interviews were transcribed primarily from video, but audio-recordings were also used to
supplement this; all transcripts were double checked by the principal investigator against the
videos, or audio recordings if needed. Although multiple coders are not necessary for the steps
outlined by Braun and Clarke (2014) for analysis, in order to increase validity regarding data
interpretation and reliability of coding, two research team members independently participated in
the coding process. Coding was done via an inductive approach, so codes were derived from the
data itself (Braun & Clarke, 2006). The first round of coding occurred when the principal
investigator and a member of the research team read through each of the transcripts individually
and generated a preliminary set of codes; these codes were labels or short phrases, sometimes
including parents’ words, which could describe a similar type of information parents received
(Braun & Clarke, 2006). Parents’ utterances were sometimes coded into more than one code
category when applicable (Braun & Clarke, 2012). Once these initial codes were established, the
principle investigator and a member of the research team separately coded the same 3 randomly
selected parent interviews, and met to discuss agreement in coding, as well as codes that needed
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refinement or clarification. The principal investigator then used NVivo 10 software to code each
transcript to facilitate the coding process and retrieval of coded text (QSR International, 2014);
the codes continued to be refined, and transcripts were reviewed multiple times throughout this
process. The principal investigator and a member of the research team then met to discuss initial
themes, which were codes that could be grouped together to describe a pattern in the data, and a
thematic map, which visually demonstrates the structure of how the themes relate to one another
(Braun & Clarke, 2006). The principal investigator then reviewed each of the themes against
individual coded excerpts, and continued making refinements to the themes and thematic map;
this process was considered complete when the uniqueness of each theme and richness of the
relationships between themes was clear (Braun & Clarke, 2006). The overarching themes and
individual codes that came from the thematic analysis of parents’ interviews can be found in
Figure 3.2; overarching themes are in bold and specific codes, which formed the themes, are
bulleted.
One purpose of the current study is to investigate the relationship between aspects of
parents’ communication and the information they receive from their early intervention service
providers. Therefore, the current study examined parents’ quantities and qualities of language
and how the presence or absence of parents’ receipt of specific information related to these
language inputs. In order to explore associations between the themes in the qualitative data and
the patterns in the quantitative data, the themes and codes from the qualitative analysis were
turned into binary variables (0s and 1s) at the code and theme levels, indicating whether the code
or theme appeared anywhere in each parents’ transcript. A score of 1 at the code level indicated
that the parent’s interview had included their receipt of specific information that was represented
by the code, and a 1 at the theme level indicated that the parent had received information for any

108

of the individual codes that were included in the theme; 0s indicated that parents had not
received information about a specific code, or any code within a theme. Figure 3.2 includes the
codes and themes that came from the qualitative analysis, and it is these codes and themes that
are then represented as 0s and 1s for each parent. For more detailed information about the
description of the themes and their relationship to one another, see Decker (in preparation).
Quotes are used in the results section of the current study to provide examples and further
depth. To create more concise quotes, […] is used when portions of a parent’s interview has been
removed. Parents’ identification numbers (#101-112) are also used throughout the results section
so that aspects of parents’ or children’s language can be matched with specific quotes.
Analytic Approach
The purpose of this study is to: 1) describe the quantities and qualities of parents’
language when they interact with their infants and toddlers who have hearing loss, and
investigate how these aspects of their language may be related to 2) the information they
received from their early intervention service providers, or 3) other important family and child
characteristics that are associated with parents’ language use and children’s outcomes. In line
with the exploratory purposes of this study, the analyses used to address this study’s aims were
exploratory and descriptive.
To address study aim 1, descriptive statistics were used to examine the variation in
quantities of parents’ language, including their word types, word tokens, and MLU. In addition,
to give perspective to the proportion of language that included speech, signs, or signs and speech
together, parents’ types and tokens that were signs and speech at the same time or signs only
were also included. Descriptive statistics were also used to examine parents’ child-directed
talkativeness, operationalized as their utterances per minute, which was determined by
combining all LTs for each parent and averaging across parents. The qualities of parents’
109

language as measured by their use of specific LTs was explored by examining the percentages of
their language inputs that were higher- and lower-level LTs, and their average use of each
individual LT per minute to determine which ones were used most frequently. More nuanced
examinations of the variations in these LTs, such as associations with parents’ language inputs
and contextual factors of the family and child, were completed as part of study aims 2 and 3.
Parents’ quantities and qualities of language inputs were treated as the dependent variable for the
remainder of the exploratory analyses.
To address study aim 2, both the overarching themes from parents’ interviews and the
individual codes were used to explore the patterns between aspects of parents’ communication
and the information that they received via their interactions with early intervention service
providers. For example, I examined whether there were any overarching patterns in the
relationship between any of the quantities or LTs of parents’ language inputs and the themes
from their interviews. Then, to investigate more nuanced patterns between aspects of parents’
language and information they had received from their service providers, I reviewed the variation
in parents’ language inputs, including word types, word tokens, MLU, and LTs as examined by
study aim 1, so that differences between parents could be more easily discovered. When a
specific quantity of parents’ language or use of a specific LT stood out from the rest of the
parents in the sample, either because their inputs were relatively more or less frequent than most
other parents’, these differences then led to taking a closer look at the information parents had
received from their service provider. I would first examine the information parents received at
the level of indicator variables, 0s and 1s as described in the Methods section, and then more in
depth by going back to the qualitative excerpts from the interviews. For example, when some

110

parents’ MLU was relatively higher than that of other parents’, I investigated if these parents’
interviews had anything in common regarding the types of the information they received.
For study aim 3, the same kind of investigation of patterns was also used to explore
whether aspects of parents’ language were related to contextual factors in these families lives. I
investigated the relationship between each of the quantities and LTs of parents’ language and
parents’ reports of household income and education. Then, I looked at descriptive statistics for
children’s use of language during free play to see if parents’ quantities of language or use of LTs
were related to any of the quantities of children’s language.
Results
Study Aim 1: Descriptions of the Quantities and Qualities of Parents’ Communication
Quantities of parents’ language. There was substantial variation across parents
regarding the quantities of their language use (see Table 3.3). On average, parents used
approximately160 different words (word types) and 550 total words (word tokens) during the 10
minute free play session with their children, and nearly 20 LTs per minute. Parents’ MLU was
approximately 3 words on average. The majority of parents’ language was spoken, given that
approximately only 4 of their word types and 8 word tokens included signs; however, as seen in
Table 3.3, one parent’s language did include a much larger percentage of signs.

111

Table 3.3
Quantities of Parents’ Language Use during Free Play
Types that
were signs Tokens that
Type/
+ speech, were signs +
Token
or signs
speech, or
ID
Types
Tokens
Ratio
only
signs only
101
198
818
0.24
1
1
102
174
704
0.25
0
0
103
132
415
0.32
6
6
104
169
580
0.29
1
3
105
152
498
0.31
37
72
106
202
711
0.28
2
5
107
160
585
0.27
0
0
108
192
698
0.28
3
4
109
152
406
0.37
0
0
110
95
216
0.44
0
0
111
184
723
0.25
0
0
112
107
320
0.33
3
3
M
159.75
556.17
0.30
4.42
7.83
SD
34.42
186.13
0.06
10.42
20.32
Range 95-202 216-818 0.24-0.44
0-37
0-72

Mean
length of
utterance
3.61
2.92
1.96
3.00
2.76
3.09
3.18
3.21
2.82
2.66
3.83
2.62
2.97
0.47
1.96-3.83

LTs/
minute
24.00
24.00
21.80
19.50
16.70
24.00
20.20
23.10
14.80
8.10
19.70
12.70
19.05
5.07
8.10-24.00

Qualities of parents’ language. Parents primarily used lower-level LTs when interacting
with their children during free play. Specifically, parents’ use of lower-level LTs accounted for
73.1% of their communication. Parents used 19.05 LTs per minute, 13.73 of which were lowerlevel LTs (SD = 3.41) and 5.33 of which were higher-level (SD = 2.33). When examining
average levels of specific LTs per minute, there were four LTs that parents used most frequently;
relatively speaking, parents used parallel talk, close-ended questions, directives, and responsive
acknowledgement the most often per minute. The average use of specific LTs per minute are
shown in Figure 3.1, some of which will be discussed in further detail below.

112

CQ

4.0

DR

3.4

Language technique

IM

0.9

LM

1.1

NO

1.3

PE

0.8

RA

2.4

PA

4.4

EX

0.2

OQ

0.5

RE

0.3

0.0

1.0

2.0
3.0
Use of language technique/minute

4.0

5.0

Figure 3.1. Parents’ average use of specific language techniques (LTs) per minute. Lower-level
LTs are above the line, and higher-level LTs are below the line.
Study Aim 2: Associations between Parents’ Communication and Information Received
First, patterns that were similar across the entire sample will be discussed. Then,
associations between individual differences in parents’ communication and information received
will be discussed.
Overarching patterns. An overarching connection between parents’ language inputs and
the information they receive about how to promote their children’s language development is that
parents are using a large amount of parallel talk (PA) on average, and all parents receive
information about the importance of frequently talking throughout all daily routines and
activities with their children. This demonstrates that parents may be internalizing this message
about talking frequently and this is then reflected in their use parallel talk, which focuses on what
their child is attending to or doing. Parents’ receipt of information about frequently talking
113

Talk frequently, all throughout the day
 Change intonation to draw attention
 Talk clearly
 Use proper enunciation, or say words ‘right’
 Use proper pronunciation
 Instruction about how to sign or using signs
 Materials or resources related to signs
 Use signs
 Ask the child questions
 Discuss general word concepts
 Narrate what you or the child is doing
 Play together
 Read books together
 Repetition
 Slow down the interaction
 Talk a lot
 Talk constantly
 Talk/discuss with the child
 Verbally label things
 Work on specific words

Promote listening and language skills by
focusing on sounds
 Encourage child to produce specific sounds
 Focus on the child’s mouth abilities,
rounding
 Draw attention to and discuss noises in the
environment
 Focus on the child’s listening skills
 Listening activities
 Focus on letters, letter sounds
 Focus on sounds—general
 Have the child wear his/her hearing aids
 Hearing aids are important
 Process of testing of child’s hearing
 Talk into the child’s better ear
 Use objects to make specific connections
with sounds

The parent is essential, most important
 I am important because I can teach him/her
 I am important—general
Incorporating other communication channels  I am more important than the service
 Exaggerate my mouth movements
provider
 Make eye contact with the child when speaking  My participation in early intervention is
 Make sure that child can see your mouth
important
 Point or gesture to my mouth/face when
 My family is important
speaking
 Parents are the language models
 Put my hand by the child’s mouth when he/she
A need for more
speaks
 Info about signs/sign language is
 Put the child’s hand to my mouth when I speak
inconsistent, lacking, or unsupportive
 Touch the child to help him/her understand
 Need additional or more specified
he/she is making noises
information because of child’s hearing loss
 When reading books have the child face me
Figure 3.2. Information parents receive about how to promote their children’s language
development.
included a variety of features, including general information about the importance of “pretty
much non-stop talking” (110) and “read to her and play with her and talk to her” (111). It also
included information about “narrating constantly” (101) as it relates it specifically to what the
child is doing or what is going on around the child, and ideas for specific “words to work on, and
how to pronounce those words so the kids can understand them” (103).

114

Importantly, the receipt of information about talking frequently could have been
internalized and expressed in parents’ communication in one of two ways—either through the
use of perpendicular (PE) or parallel talk (PA). If parents had internalized the information about
frequent communication in such a way that led to their discussion of anything and everything,
without regard to their child’s focus or attention, this could lead to greater frequencies of
perpendicular talk. However, parents’ use of perpendicular talk is far less frequent than their use
of parallel talk (see Figure 3.1), suggesting that parents may interpret the various aspects of
information about frequently talking in a way that relates to an awareness of their child’s focus.
It is important to take into consideration another aspect of information that parents
receive—specifically, to incorporate other communication channels—since this may be what
drives this pattern between information about talking frequently and parents’ use of parallel talk,
as opposed to perpendicular talk. Parents received information about the importance of eye
contact in general (e.g., “Make sure you look at her and she knows you’re talking [in order for
her] to hear it.” (109)), as well as purposefully drawing attention to their mouths (e.g., “Mouth
movements, make sure she can see your mouth, or point to your mouth and say ‘open’
[exaggerated sound: ‘oooh-pen’].” (103)). This information about communication channels may
encourage parents to consider their child’s attention, or for them to either try to get their child’s
attention or wait for it before communicating; this could then translate into their use of parallel
talk, since this occurs when parents communicate about things that are related to what the child
is doing or the child’s focus of attention.
Although all parents received information that related to the theme of talking frequently,
it is important to note that they also discussed how this can be challenging. Some examples from
parents’ interviews that demonstrated this included the following:

115

Basically they just said I have to talk constantly. Which I find I don’t really-, I don’t-, I
can’t do it all the time. Well I definitely narrate during playtime, that’s when we’re
talking constantly. But sometimes it just seems so unnatural. (101)
Our role is to teach her how to get through the day, and to communicate. Talk and talk
and talk and talk! Which is hard for some people, and it is. Some days it’s really hard for
me. (104)
[My service provider] walks around the house and points at stuff: mirror, wall, door.
She’s done that before. […] Which is a little easier said than done. Trying to walk around
the house and [label], ‘Wall, door,’ [my child is] like, ‘I don’t care mom!’ (103)
Therefore, parallel talk may be challenging for some parents, or they may only feel
comfortable using this type of communication a certain amount and may supplement their
communication by using other techniques. Importantly, there are, in fact, nuances in parents’ use
of parallel talk which will be discussed in more depth below.
Quantities of language input. There were nuances in the particular types of information
that parents receive within the theme of the importance of frequent communication and there is
also a great deal of variation in the quantities of parents’ language input. Of the quantities of
parents’ language examined, which included word types, word tokens, MLU, and LTs per
minute, patterns emerged between parents’ use of LTs per minute and MLU and their receipt of
information.
Regarding the pattern between parents’ use of LTs per minute, certain parents did not
receive information related to the specific code of ‘talk constantly,’ even though all parents
received information related to the theme of talking frequently. In particular, parents 105, 108,
109, 111, and 112 did not receive this particular message to talk constantly, although they
received other types of information about the importance of talking with their child and/or
engaging in communication with their child throughout everyday routines. It is worth mentioning
that of these 5 parents, 3 of these parents (105, 109, and 112) were in the bottom quarter of

116

parents regarding their use of the fewest LTs per minute (see Figure 3.3). Therefore, even though
all parents received information about the importance of frequently talking with their children,
not receiving the specific piece of information to ‘talk constantly’ may be related to some parents
being less talkative overall, as measured by their utterances per minute.

101

24.0

102

24.0

103

21.8

104

19.5

Parent ID

105

16.7

106

24.0

107

20.2

108

23.1

109

14.8

110

8.1

111

19.7

112

12.7
0.0

5.0

10.0
15.0
20.0
Use of language techniques/minute

Figure 3.3. Parents’ average use of language techniques (LTs) per minute.

117

25.0

30.0

Parents average MLU was approximately 3 words per utterance (M = 2.97, SD = 0.47).
Parent 103’s MLU was the lowest in comparison to all other parents in the sample and was 1
standard deviation below the mean (see Figure 3.4). For parent 103, it is important to note that
this is the only parent in the sample who received information related to the code of ‘verbally
label things.’ In particular, this parent discussed receiving information about pointing out and
labeling specific things when interacting with her daughter, and also received information about
particular words or concepts to discuss with her child (e.g., in/under, above/below, open/close).
Table 3.4 includes an excerpt from the play session between parent and child 103,
including the coding of the parents’ use of LTs (noted on the %spa lines), while they were
interacting with stacking rings. This excerpt illustrates that parent 103, although frequently using
parallel talk which is a higher-level LT (also see the following section), is doing this while using
one word at a time to label her child’s actions of taking the rings on and off the toy. This
demonstrates that providing parents with information about labeling objects may negatively
influence parents’ use of longer utterances when interacting with their children.
Table 3.4
Excerpt from Free Play between Parent-Child Dyad 103
*MOT: On.
%spa: PA
*MOT: On.
%spa: PA
*MOT: On.
%spa: PA
*MOT: One more.
%spa: DR
*MOT: Right here.
%spa: PA
*MOT: On.
%spa: PA
*CHI: More.
*MOT: More?
%spa: RE
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Higher-level language techniques. Examining parents’ use of higher-level LTs shows
that the majority of their use of these techniques is driven by parallel talk; parents used parallel
talk 4.4 times per minute on average, but there is also a great deal of variation in this between
parents (SD = 2.12). As seen in Figure 3.5, there are three parents whose use of parallel talk is 78 times per minute, which is considerably higher comparison to the other groups of parents who
use parallel talk 1-4 times per minute. These parents, 103, 106, and 111, are using approximately
1.5-5 times more parallel talk than other parents in the sample. By exploring the information
these parents receive from their service providers in comparison to other parents who are using
lower levels of parallel talk, there are interesting differences that emerge. Specifically, parent
103 discussed a variety of detailed information that she receives, such as particular letter sounds,
words, or concepts to incorporate into her interactions with her daughter. For example, she said:
“Our provider… basically gives us something to work on once a week. The K’s, the P’s.
A couple weeks ago they were helping her understand ‘in’ and ‘under,’ ‘above’ and
‘below,’ ‘open’ and ‘close.’ So every week we have something new… She asked me if I
had heard [my child make] a ‘K’ sound and I’m like, ‘I don’t think so,’ you know, and
then we started 'kick' [and kicking the ball] and now she’s got it. […] After we did ‘open’
and ‘close’ [with small food containers], then we added onto it and made her say ‘eat’ or
‘more’ instead of ‘open.’” (103)
Since this parent received information that relates to everyday routines and activities that
she already does with her daughter, such as playing outside and eating together, this may mean
that this parent is able to easily incorporate this information into her interactions with her child.
In particular, this specific information provides the parent with ideas about creating opportunities
to talk with her child when she will have her child’s attention on a particular object or action,
which is a necessary component of interactions in order for parents’ language to be considered
parallel talk.

119

101

3.5

102

4.9

103

7.9

104

4.5

Parent ID

105

4.2

106

7.3

107

4

108

3.6

109

2.6

110

1.3

111

7

112

1.7
0

2

4

6

8

10

Use of parellel talk/minute

Figure 3.5. Parents’ use of parallel talk (PA) per minute.

It is worth mentioning that other parents also discussed receiving specific information
about activities to do with their children during play, such as connecting sounds to objects and
creating opportunities for joint attention in which to communicate (e.g., “The speech therapist
has been good about giving us exercises to do with him. […] She had these ice cream cones
she’d use for ‘mm’, she had a mouse for ‘ee.’” (105)), but most of the time the information that
parents received was more broad (e.g., to read books, play together, talk with the child).
However, parent 103 discussed the information that she receives in a way that demonstrated how
ingrained it is throughout the day with her daughter, and she was the parent who gave the most
specific examples of information that she receives from her service provider.
The two other parents, whose use of parallel talk was much higher on average, were
parents 106 and 111. While a number of parents discussed their need for additional specific
120

information as it pertains to their child’s hearing loss in order to continue to feel supported to
promote their children’s language development, these were two parents who talked about this in
much more depth during their interviews. This leads to questions about how parents’ current skill
levels may influence their desire for more specific information. For example, parent 106 talked
about the information that she receives as “unsophisticated” and that the purpose of it is not
always clear, while parent 111 said:
The most important thing is I want [the service provider] to know that I wish that there
was specific things for all ages. Not just, ‘oh, it’s a baby, and because she can’t talk,
you’re doing fine, just read to her and play with her.’ You know? […] There’s gotta be
more specific stuff, I just know there is. I just know it. (111)
In summary, when parents’ receive of very specific information about ideas of ways to
communicate with their children within the context of a joint activity this may be particularly
important for promoting parents’ use of parallel talk. However, for other parents, it is possible
that when they are already frequently communicating about what it is their child is attending to
or doing, and therefore using parallel talk, they may feel that the information they receive is not
adequate or specific enough. Therefore, if parents are already communicating with their children
in ways that align with certain LTs that are of important for the language development of
children with hearing loss, this may also drive their feelings that there must be more
sophisticated or specific information that they need to receive in order to continue to feel
supported.
Study Aim 3: Associations between Parents’ Communication and Contextual Factors
Family socioeconomic status. Examination of families’ level of income and parental
education revealed patterns between the quantities of parents’ language input, as well as one
particular LT. The parent whose family income and education were in the lowest categories
reported in this sample (income between $12,000-19,999 and a high school diploma or GED),
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used the lowest number of word types, word tokens, and LTs per minute while interacting with
her child (see parent 110 in Table 3.3). Exploring both the percentage of parents’ language that
included specific LTs and their rates of LTs per minute, there are three parents, 102, 109, and
110, whose use of directives (DR) was relatively higher than others. Across the entire sample,
parents used directives 3.8 times per minute on average (SD = 1.75, range = 1.10-7.90) and for
19.4% of their total language (SD = 11.9%, range = 5.7-43.2%). Parents 102, 109, and 110 used
more directives compared to any other LT while playing with their child, at 7.9, 5.6, and 3.5
times per minute, respectively. Though parent 110’s rate of 3.5 times per minute seems close to
the overall average across all parents (3.8 times/minute), looking at the percentage of this
parent’s communication is important considering that this parent used the least amount of
communication compared to all other parents, as mentioned above. Parent 110’s use of directives
was approximately 43.2% of her overall use of LTs, which is approximately 2 standard
deviations above the mean. Although there are no identifiable differences in the information
these three parents received, there is a difference in their income level. These parents are the
three whose families’ annual household incomes were in the lowest category reported in this
sample.
The results related to families’ income level and parental education suggest that SES may
influence both the quantities and qualities of their language input. However, it should be noted
that of the three parents discussed the section above, 102, 109, and 110, their children’s language
skills were among the lowest in the sample (see Table 3.5). This may mean that when the
quantities of parents’ language are lower or include more lower-level LTs, particularly
directives, this may negatively influence children’s language skills. On the other hand, this may

122

demonstrate a child effect: when children have lower language skills, their parents may adapt
their use of language in ways that include more lower-level LTs.
Children’s language use. When examining other relationships between children’s
current language skills and parents’ quantities of language and use of LTs, there was a
relationship between children’s language skills and parents’ use of specific higher-level LTs.
Given that parents used a great deal of parallel talk, and the three other higher-level LTs—openended questions, expansion, and recast—were used much more infrequently, these three
techniques were combined and examined separately so that parents’ use of parallel talk did not
conceal the nuances in the use of other higher-level LTs. When these three higher-level language
techniques were combined, parents used approximately 1 higher-level LT per minute while
playing with their child (M = 0.95, SD = 0.92).
There are two parents who used relatively greater levels of these higher-level techniques
in comparison to others (see Figure 3.6). Parent 101 and 108’s use of these higher-level LTs
during their interactions with their children is nearly 2 standard deviations above the mean.
Exploring the information received for these two parents did not suggest that these parents
received substantially different information from their service providers. However, there are
patterns in the differences of the language skills that their children demonstrated during free
play. There was a great deal of variation in children’s language skills, as approximated by their
language use during free play; children used approximately 14 word types and 41 word tokens
(word types: SD = 13.6, range = 1-45; word tokens, SD = 41.2, range = 20-151; see Table 3.3).
Children in dyads 101 and 108 used the most word types of all children in the sample, which is
an indicator of children’s vocabularies (e.g., Pan, Rowe, Spier, & Tamis-LeMonda, 2004). As
seen in Table 3.5, children in dyad 101 and 108 used 30 and 45 word types, which was more than

123

1 standard deviation above the mean. However, proxies for these children’s overall talkativeness
(word tokens) or age does not yield the same pattern. This may mean that it is children’s
vocabulary, rather than their overall talkativeness or age, that is related to parents’ use of higherlevel LTs. It is possible that when parents use more higher-level LTs with their children this
promotes children’s expressive language skills, or that children with greater expressive language
skills may elicit their parents’ use of these higher-level LTs.

124

101

2.8

102

0.6

103

1.4

Parent ID

104

0.5
0.9

105
106

0.6

OQ

107

1

EX

108

2.7

109

RE

0.1

110

0.3

111

0.2
0.3

112

0

0.5

1

1.5

2

2.5

3

Use of open-ended questions, expansion, and recast/minute

Figure 3.6. Parents’ use of open-ended questions (OQ), expansion (EX), and recast (RE) per
minute.

Table 3.5
Children’s Language Use during Free Play and Their Age in
Months
ID
Types
Tokens
Child age (in months)
101
30
58
24.9
102
2
22
20.9
103
21
69
25.1
104
12
46
20.8
105
19
24
29.5
106
9
34
18.6
107
6
50
17.9
108
45
151
29.4
109
2
31
15.6
110
2
20
15.8
111
1
35
12.0
112
21
122
29.0
M
14.2
55.2
21.6
SD
13.6
41.2
6.0
Range
1-45
20-151
12.0-29.5

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Post-hoc Analysis: Parents’ Communication Modalities and Receipt of Information about
Signs
Based on the descriptive results of parents’ language use, which indicated that the
majority of parents in this sample did not use many signs (see Table 3.3), an examination of the
relationship between parents’ use of signs and their receipt of information about signs was
completed post-hoc. There does not appear to be a clear relationship between these data. Of the
12 parents in the study, 7 used signs while interacting with their children—4 of which had not
received information about the use of signs. Importantly, 6 of these 7 parents who used signs did
so in a minimal way in comparison to their overall communicative types and tokens, such that it
accounted for 0.12-1.45% of their total tokens. However, one parent’s use of signs accounted for
14.46% of the total tokens, and this parent did not report receiving information about signs;
instead, this parent talked at length about the lack of support and information received about the
use of signs or sign language.
In addition, this parent, as well as 5 others in the study reported a desire for additional
information regarding the use of signs, including both those who used some signs and those who
did not use signs at all during the free play interaction. It is possible that parents’ use of signs
may be about the personal choice their family has made about using signs, rather than about
specific information they receive, potentially because they are not receiving enough information
or support from their service providers. This may be related to the types of information parents
receive about the use of signs, given that the information that parents do receive about the use of
signs is usually in the form of pictures of signs or websites to visit (e.g., “handouts on sign
language” (103); “They gave me the signs and stuff. They printed out like little booklets to work
on.” (104)).

126

Discussion
This study found that the majority of parents’ language inputs to their infants and toddlers
with hearing loss included lower-level language techniques and the majority of their use of
higher-level language techniques was driven by the use of parallel talk; this is in line with the
only other study to date that has focused on very young children with hearing loss (e.g., Cruz et
al., 2013). Importantly, there was also a great deal of variability in the quantities of parents’
language and in the specific language techniques they used.
The similarities across parents, as well as the individual differences among them, were
used as a basis to then explore how these quantities and qualities of their language may vary as a
function of aspects of their early intervention services or other contextual factors. The current
study is the first of its kind to investigate the relationship between parents’ language inputs and
the information they receive as part of early intervention services. Overarching patterns in the
data show that parents’ use of parallel talk may be influenced not only by their receipt of
information about the importance of frequently talking with their child throughout all daily
routines and activities, but the receipt of this information in conjunction with information that
may encourage joint attention between children and their parents. Specifically, parents also
received information about the importance of incorporating other communication channels, such
as eye contact and touch, and to focus on sounds; both of these kinds of information may provide
parents with ways to create opportunities for joint attention in their interactions with their
children, and to use language in these interactions.
More nuanced patterns between individual pieces of information parents received and
their language use show that although all parents receive information about the importance of
frequently talking with their children, it may be beneficial for some parents to receive more

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explicit information about what ‘frequently’ may mean in order to potentially increase their
overall talkativeness. Another piece of information that may influence the quantities of parents’
language is receiving information to use labels to describe objects or actions; receiving
information about labeling things may hinder parents’ mean length of utterance, and if it is not
done within the context of joint attention it is shown to be detrimental for the language
development of children with hearing loss (DesJardin, 2006). Receiving information about
labeling may come at the expense of more rich language interactions between parents and their
children. Thus, parents may need more specific information about using multiple words while
providing labels, and to do this when it describes what their children are attending to or doing.
Additional patterns related to the qualities of parents’ language show that receiving
information about specific activities to do with their children may promote their use of parallel
talk; this type of information may provide parents with ideas about discussing what their children
are attending to or doing, which is a necessary component of parallel talk (e.g., DesJardin, 2006;
DesJardin & Eisenberg, 2007; Cruz et al., 2013). However, the findings of this study show that
when parents are frequently using parallel talk, they may be the parents who are most in need of
additional, specific information. There is reason to believe that if parents’ language use is already
in line with the recommendations they receive from their service providers, such as to frequently
talk to their children and use communication channels and sounds as an opportunity to engage in
joint attention, they may feel as if the information they receive is not enough to help them
promote their children’s language development; these parents need additional information in
order to feel like the recommendations that they receive are meaningful and that they have the
information to strengthen their interactions with their children in order to make a difference in
their children’s language development. Overall, these findings are the first to test the hypothesis

128

that parents’ language inputs may be influenced by the information they receive as part of early
intervention services, which is frequently mentioned as implications of research studies that
examine how variation in parents’ language influences the language skills of children with
hearing loss (e.g., DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam, et
al., 2012; Ambrose et al., 2014).
Investigating other contextual aspects of these families lives shows there are relationships
between the quantities and qualities of parents’ language and families’ SES. The findings of the
current study demonstrate that children of lower SES families may be exposed to fewer different
and overall words, and the qualities of their parents’ language may include more directives,
which aligns with other research studies about the influences of parental SES (Hart & Risley,
1995; Niparko et al., 2010; Barker et al., 2009; Geers et al., 2009; Szagun & Stumper, 2012;
Cruz et al., 2013), Thus, parents of lower SES may need additional supports about the
importance of the combination of frequently talking while following their children’s lead.
Furthermore, parents who use relatively more frequent directives have children whose
language skills were among the lowest in the sample, while parents whose children had the
greatest language skills used considerably more of the higher-level language techniques. These
findings are consistent with previous studies, which suggest that directives may be detrimental,
while expansion, recast, and open-ended questions may be predictive of the language
development of children with hearing loss (DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz
et al., 2013). However, these findings may also demonstrate that parents are adjusting their use
of language techniques based on their children’s current skill levels, with parents using more
lower-level techniques with their children whose language skills are less advanced and more
higher-level techniques with children whose skills are greater, which has also been suggested by

129

past research (Farran et al., 2009, Lederberg & Prezbindowski, 2000). Regardless of
directionality, the findings of the current study, in combination with research related to the
language techniques that promote the language development of children with hearing loss
(DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013), suggest that parents may
need to be provided with information about the specific language techniques known to support
their children’s language development since these may be different than those that are best for
younger children who have typical hearing or who have language delays (Girolametto et al.,
1999; Tamis-LeMonda et al., 2001; McNeil & Fowler, 1999; Dale et al., 1996; Yoder et al.,
2001; Dale, Crain-Thoreson, Notari-Syverson, & Cole, 1996).
Implications for Practice
In line with the theory of social constructionism (Gergen, 1985; Lock & Strong, 2010;
Burr, 1995), this study shows that the information parents receive from their service providers
has the potential to influence both the quantities and qualities of the language that they use when
interacting with their children. In particular, this study shows the importance of parents receiving
information about frequently talking with their children since this may contribute to their use of
parallel talk, but that also providing parents with additional information about ways to create
opportunities for joint attention is key to this process. Providing parents with information about
increasing the quantity of their language is not enough; instead they need to simultaneously
receive messages about the importance of the quality of their interactions with their children, in
particular, the importance of talking frequently about their child’s interests or actions. Therefore,
providing these families with information about the quantity of their language should be done in
conjunction with the importance of the quality of these interactions, and the most important
quality is to discuss what it is that their child is attending to or doing.

130

The findings from this study also demonstrate that it may be particularly helpful to
parents if the information they receive is based on their current strengths. Parallel talk is an
important quality of parents’ language and it is also one that may be approachable for parents,
given that it was the most common language technique used; therefore, parallel talk may provide
a foundation for promoting specific qualities of parents’ language. The results of this study
suggest that parents whose language includes frequent levels of parallel talk may be at a stage
where they are ready to receive information about the more complex higher-level language
techniques (e.g., open-ended questions, expansion, and recast) in order to feel as if the
information they receive is adequate enough to support them in their continued efforts to
promote their children’s language skills.
The post-hoc analysis of this study shows that parents want additional information and
support regarding the use of signs or sign language, and they may not be currently receiving
enough information in order to use this modality of language with their children. It is important
that parents are supported in their decisions regarding the method of communication they will
use with their children (Moeller et al., 2013; Yoshinaga-Itano, 2014; JCIH, 2007). In order to do
this, parents need information that provides them with examples and opportunities to practice the
language itself, rather than individual components.
Limitations
This study is limited in generalizability for a variety of reasons, including being drawn
from a small sample and the fact that all families came from one limited geographic area.
Although there was variation in families’ income levels and parents’ education, the majority of
parents in this study had relatively high levels of socioeconomic status. The lack of variation in
parents’ and children’s race/ethnicity means that the experiences of other types of families are

131

not represented in these data. Future research should make concerted efforts to recruit
participants from more diverse families, since these families’ experiences may be different and,
therefore, influence their interactions with their children in unique ways.
Although this study suggests that the information parents receive as part of early
intervention services may influence the quantities and qualities of their language, the
directionality in these relationships cannot be assumed. Furthermore, the information parents’
receive from their service providers was only from the retrospective account of the parents,
which may mean that other types of information provided to parents, or the ways in which
information is provided, may potentially guide the relationships between these services and
parents’ language inputs.
Future Directions
To better understand the ways in which parents’ language inputs may be influenced by
the information parents receive about how to promote their children’s language development as
part of early intervention services, longitudinal studies that focus on both observation of early
intervention services as well as parents’ reports of information received, would be most
influential. Longitudinal studies would allow for analytic approaches that could test
directionality; it is possible that there are sensitive periods of time when certain information may
be more influential when provided to parents, and testing this longitudinally would allow for
family-centered early intervention to be more sensitive to parents’ needs, as well as to the critical
periods of children’s language development when certain aspects of parents’ language inputs
may be most influential. Measuring the information parents’ receive and how it is provided, via
both observation and parents’ reports over time, would provide an opportunity to better
understand how the information provided to parents aligns with best practices and what specific

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aspects of this information provided to parents or that parents remember is most critical to
positively influencing their interactions with their infants and toddlers who have hearing loss.
Furthermore, future studies should examine service providers’ reports of the information
they provide to parents about how to promote the language development of children with hearing
loss. This would help identify gaps between information service providers feel that they are
giving to parents and parents’ perceptions of this information. This may provide insight as to the
types of information that may be provided to parents, but not internalized and incorporated into
their interactions with their children who have hearing loss.

133

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CHAPTER 4: INTEGRATIVE CONCLUSION
Contribution to Existing Literature
Together, these studies were intended to fill a gap in the literature related to the
information parents’ receive from early intervention service providers about how to promote the
language skills of their young children with hearing loss, and the relationship between this
information and specific quantities and qualities of parents’ language that are known to influence
the language development of these children. These studies help to shed light on how early
intervention influences these families by identifying patterns in the information parents’ receive
from their service providers which then relate to some of the variations in the ways these parents
communicate with their children.
Study 1 demonstrates that the information parents receive is partially in line with best
practices. More specifically, results of Study 1 show that, central to all of the information they
received, was the importance of frequently talking to their child by embedding language into all
of their daily activities; parents received information about how these are learning opportunities
for their children, regardless of how mundane these activities seem. This is in line with researchbased best practice recommendations in a few distinct ways: parents received information about
a way to enhance their children’s everyday language environments (e.g., Moeller, Carr, Seaver,
Stredler-Brown, & Holzinger, 2013; Spencer & Marschark, 2010; Marschark, 2007; Joint
Committee on Infant Hearing (JCIH), 2007; Yoshinaga-Itano, 2014), and this information was
provided in a way that aligned with their everyday routines, which demonstrates the importance
of the children’s parents and home lives to their learning (e.g., Division for Early Childhood,
2014; Moeller et al., 2013; JCIH, 2007; Workgroup on Principles and Practices in Natural
Environments, 2008). Furthermore, not only did parents receive information about the

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importance of frequently talking with their children, but they also received information about
other ways in which to support children’s language development, such as focusing on sounds and
incorporating other communication channels. These findings align research that shows the
importance of the frequency of parents’ language (Hart & Risley, 1995) within the context of
joint attention (e.g., Barker et al., 2009; Lederberg & Prezbindowski, 2000).
Furthermore, parents also received straightforward information about their importance,
which is in line with best practices that focus on the importance of parental self-efficacy
(Division for Early Childhood, 2014; Moeller et al., 2013). Parents were provided with
information about how they are the most important individual in their child’s life, and their
involvement in early intervention and follow-through with the suggestions made by their service
provider are important to their child’s development. Parents were told their importance
outweighs that of the service provider; they received information about how the service provider
is there to help the parent.
However, the findings from Study 1 also demonstrate that there is additional information
that should be provided to parents in order for them to feel fully supported. In particular, parents
felt that they did not receive enough information regarding the use of sign language, even though
best practices including empowering parents to make decisions about their children; for parents
of children with hearing loss, one of the decisions they will make relates to their child’s mode(s)
of communication, and it is important that these decisions are respected (Moeller et al., 2013;
JCIH, 2007; Yoshinaga-Itano, 2014). Best practices for children with hearing loss reflect an
unbiased and in-depth presentation of information to parents regarding communication options
(Moeller et al., 2013; JCIH, 2007; Yoshinaga-Itano, 2014). This calls for additional attention to

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be paid to supporting service providers to be more able or willing to offer these particular types
of information and unbiased support.
Furthermore, there are also other gaps in the information that parents received based on
what research suggests can be influential to the language development of young children. For
example, in Study 1 parents receive information about frequently talking, demonstrating a bias in
toward spoken communication; this demonstrates that there is a need for this information to
discuss the important aspects of communication that includes any modality of language (Moeller
et al., 2013; Yoshinaga-Itano, 2014). In addition, parents also discussed that they need to be
provided with information about more nuanced ways in which to support their children’s
development; best practices discuss the importance of service providers giving parents’ strategies
for ways to promote their children’s language development (Yoshinaga-Itano, 2014) and
supporting parents’ use of the specific language techniques that are shown to promote children’s
language development (Moeller et al., 2013). Study 1 shows that parents did not receive
information about specific quantities or qualities of language to use with their children, despite
that this is a suggested best practice (e.g., Moeller et al., 2013; Yoshinaga-Itano, 2014; JCIH,
2007).
Study 2 shows that when parents receive information about the importance of frequently
communicating with their children, and when this information is supplemented by additional
suggestions that provide parents with opportunities to communicate with their children within the
context of joint attention, that this is related to parents’ use of parallel talk. Furthermore, when
parents receive very specific ideas about ways to incorporate suggestions into their everyday
routines and activities with their children, this also promotes parents’ use of parallel talk. Both of
these findings are positive, given that parents’ use of parallel talk is important for the language

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development of children with hearing loss (Cruz, Quittner, Marker, DesJardin, & CDaCI
Investigative Team, 2013). Study 2 also shows that parents of lower socioeconomic status may
need additional supports to increase their overall talkativeness and to transition their language
away from using directives to instead beginning to follow their children’s lead.
When taken together, these studies show that parents want additional, nuanced
information about how they can promote their children’s language development, and this is
especially true when they may already be using one important technique, parallel talk. When
parents’ language inputs already include a foundation in the specific language techniques that are
shown to be important to their children, they need more detailed and explicit information about
how to continue improving their skills. These studies also demonstrate that parents need
additional information about the use of signs or sign language, and the types of information they
receive at this point, such as handouts or websites to use, are not enough to support their use of
sign language.
Implications for Practice
Taken together, these studies show that parents receive a wide variety of information
about how to promote their child’s language development and the important role they have in
this process, and this influences aspects of their communication in specific ways. However, in
light of previous research which showed that specific quantities and qualities of parents’
communication are known to be predictive of the language development of children with hearing
loss (DesJardin, 2006; DesJardin & Eisenberg, 2007; Cruz et al., 2013; VanDam, Ambrose, &
Moeller, 2012; Ambrose, VanDam, & Moeller, 2014), Study 1 suggests that parents need to be
provided with more specific information about how increasing these aspects of their language
when communicating with their children, regardless of the modality of language used, can be

145

very beneficial for their children. Study 1 shows this in two separate ways; first and foremost,
parents did not report that they received information about any of these quantities or qualities
beyond talking frequently, which would relate to the overall number of words parents used,
which has been not been shown to be associated with the language development of children with
hearing loss (VanDam et al., 2012; Ambrose et al., 2014). Parents need to receive information
beyond the pure quantity of their language, since quantity of language alone is not predictive of
their children’s language skills in absence of rich vocabulary (word types) and discussions that
respond to children’s vocalizations or actions (e.g., DesJardin, 2006; DesJardin & Eisenberg,
2007; Cruz et al., 2013; VanDam et al., 2012; Ambrose et al., 2014). Secondly, Study 1
demonstrates the need for more specific information for parents, because this is what they feel is
missing from the information they already receive. Parents discussed how the information they
receive seems generic and that it could relate to any type of child, rather than their child who has
specific needs because of his/her hearing loss.
Study 1 also demonstrates that there is a need for service providers to increase the
amount of information and support they provide to parents regarding the use of sign language.
This study also demonstrates that service providers may need additional training and support to
learn about the importance of providing unbiased information and support to parents, and that the
use of sign language will not impede a child’s ability to acquire spoken language, if this is also a
goal for the parents. Although parents reported that they received information about the use of
individual signs, they did not seem satisfied with this; they discussed their need for additional
information, and that receiving this information would also show that their service provider
supported the communication options they were considering or had already decided upon.

146

The results of Study 2 demonstrate that there is an opportunity to build on parents’
strengths. Parents received information about the importance of frequently talking with their
children, and of all the language techniques they used with their children, parallel talk was used
most frequently. Given that parallel talk is a language technique that is positively associated with
the language development of children with hearing loss (Cruz et al., 2013), these findings and the
potential relationship between parents’ use of parallel talk and the receipt of information about
frequently talking, is positive. Parents’ use of parallel talk provides an opportunity to build on
and expand their skills. For example, when service providers notice that parents’ are frequently
using parallel talk, this may provide a bridge to incorporating more of the other higher-level
language techniques. For example, for parents’ who are already discussing their child’s actions
or what the child is attending to, this may provide a good opportunity to encourage parents to
then ask their children open-ended questions regarding their actions (e.g., “What are you doing
with the baby doll?”) or what they are attending to (e.g., “What are you going to do with that
one?”).
Future Directions
The findings of these studies could be strengthened by observing early intervention
services in order to directly assess the information provided to families, as well as the ways in
which this information is provided. This would provide an opportunity to further inform early
intervention practices and training of service providers. Observational studies of this kind would
lead to a better understanding of the alignment between recommendations of best practices and
research, and the information provided to families; it would also clarify particular areas of
weakness that need to be addressed.

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However, this would not address the potentially most influential aspect of the theory of
change: the messages that parents internalize, and how these influence their language inputs.
Even if families are provided with information that completely aligns with the best practices and
research recommendations made in the field, there is still uncertainty regarding what it is that
parents take from this process. It is parents’ internalization and understanding of this
information, rather than information actually provided by service providers, that has the potential
to be most influential to their interactions with their children and, subsequently, their children’s
language development. Therefore, particularly informative studies would be those that
combined: a) direct observation of early intervention services provided to families, including
information provided to families, as well as the ways in which this information is provided, b)
parent reports of information received, and c) direct observations of parent-child interactions.
Studies of this kind would allow for a better understanding of the gaps between the information
provided to parents and what parents actually internalize, what may explain these gaps, and
would further add to our limited understanding of the particular information provided and
internalized that is predictive of the quantities and qualities of parents’ language input. This
would also provide an opportunity to see how individual variation in the information provided to
parents and their internalization of this information may relate to specific aspects of their
language inputs. Studies of this kind would also allow for a continued exploration of how
specific quantities and qualities of parents’ language inputs, potentially influenced by the
variation in information they receive, influence children’s language skills over time.

148

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